PROVIDER HANDBOOK Care...This handbook is an important part of your Contractual Agreement with NMHC...

PROVIDER HANDBOOK

myNMHC.org

ID0018-0619 New Mexico Health Connections Provider Handbook

INTRODUCTION New Mexico Health Connections (NMHC) is committed to providing the highest quality of care to its members, and driving improvements in quality more broadly in the community. The vision of NMHC, as a non-profit Consumer Operated and Oriented Plan (CO-OP), is to bring a life-improving revolution in health to New Mexicans through partnerships with our members, providers, and communities. NMHC is a non-profit Consumer Operated and Oriented Plan (CO-OP) that serves New Mexicans starting in 2014. Created by the Affordable Care Act (ACA), CO-OP plans give consumers and small businesses more options for health insurance, providing required ACA essential health benefits (EHBs) and other federal or state mandated benefits, while complying with regulations defined by state and federal law. A key concept of the CO-OP program is to drive implementation of integrated care and payment models producing improved health outcomes while “bending the cost curve,” if not actually lowering aggregate costs. NMHC understands the importance of building programs that will influence our members’ health behaviors, resulting in positive, sustainable health outcomes. In partnership with our members, provider network, and communities, we seek to ensure a clinically integrated approach to improving health care quality and access to care statewide. This handbook is an important part of your Contractual Agreement with NMHC and is intended to provide NMHC network practitioners, their staff, and the larger health care delivery system the information, tools, and guidance needed to facilitate care and services for NMHC members.


CONTACT INFORMATION Address New Mexico Health Connections P.O. Box 36719 Albuquerque, NM 87176 Provider Portal Login Providers contracted with NMHC can locate eligibility and benefits, claim status and referral inquiry, contracted medical providers, medical and administrative policies, and much more through our provider portal. If your facility does not yet have access, register now at http://mynmhc.org/. Click on My Account Login.

Area Phone (Toll-Free) Fax Web

Customer Care 1-855-7MY-NMHC (1-855-769-6642) 1-361-904-0187 http://www.mynmhc.org/Contact_Us.aspx

Credentialing

1-855-7MY-NMHC (1-855-769-6642)

1-800-947-8701 http://www.mynmhc.org/credentialing-re-credentialing.aspx

Provider Services 1-888-282-3483 http://www.mynmhc.org/Health_Care_Pr

ofessionals.aspx Medical Management 1-866-628-3047

http://www.mynmhc.org/medical-management.aspx

Prior, Concurrent, and Expedited Authorizations

1-866-628-3047

Pharmacy Administration, Including Prior, Concurrent, and Expedited Authorizations for Medications

1-855-577-6550 1-866-511-2202 https://www.optum.com/landing/rx/pharmacycareservices/physicians.html

Paper Claims Submission Address New Mexico Health Connections P.O. Box 211468 Eagan, MN 55121 Change Healthcare (previously known as Emdeon) NMHC Payer ID: 45129

http://mynmhc.org/

http://www.mynmhc.org/Contact_Us.aspx

http://www.mynmhc.org/credentialing-re-credentialing.aspx

http://www.mynmhc.org/credentialing-re-credentialing.aspx

http://www.mynmhc.org/Health_Care_Professionals.aspx

http://www.mynmhc.org/Health_Care_Professionals.aspx



https://www.optum.com/landing/rx/pharmacycareservices/physicians.html

https://www.optum.com/landing/rx/pharmacycareservices/physicians.html


Language Line We offer translation and interpretation services in Spanish, Navajo/Diné, and more than 200 other languages. If you need translation or interpretation services during a visit with one of our members, call the Customer Care Center toll-free at 1-855-7MY-NMHC (1-855-769-6642) for help. Provider Newsletter: NMHC Provider Connection Four times a year, we share important news, updates, and information that affects your practice and our patients. NMHC Provider Connection is sent via email in March, June, September, and December and also posted on the Provider Forms and Other Resources page of our website, http://www.mynmhc.org/provider-resources.aspx. If you are not receiving our quarterly provider newsletter and want to, please send an email to [email protected] with your name and the name of your practice, or call your Provider Services representative.

http://www.mynmhc.org/provider-resources.aspx

mailto:[email protected]


QUALITY PROGRAM The goal of the NMHC Quality Improvement Program (QIP) is to develop, implement, and maintain a quality program that meets the unique and diverse needs of our membership, New Mexico communities, and of the health care delivery system. The program’s intent is to deliver care that exceeds expectations, promotes innovation in reimbursement strategies and opportunities to change health behaviors, and incorporates highly integrated clinical care approaches to improve health outcomes. Implementation of NMHC’s quality plan supports service delivery, quality health care, and patient safety for our members. The promotion of quality, enabled, and sustained through the creation of appropriate infrastructure, requires the following:

• Ensuring Qualified Health Plan (QHP) and National Committee for Quality Assurance (NCQA) Accreditation status.

• Ensuring compliance with ACA and state regulations, rules, and legislation. • Developing an integrated set of core services, programs, and interventions to improve health

outcomes of members while actively engaging providers. • Developing effective monitoring and evaluation programs of health care services to meet or

exceed current standards while identifying opportunities for continuous improvement and subsequent implementation of solutions.

• Developing effective processes and educational opportunities to reduce medical errors and improve patient safety.

• Identifying and responding to health care disparity issues to improve quality of care. • Developing and implementing programs in alignment with ACA. • Implementing and evaluating the quality improvement program and activities to be aligned with

the National Strategy for Quality Improvement in Health Care. The NMHC QIP activities are integrated within all health plan operations and provide mechanisms for the coordination of quality improvement, medical and behavioral health management, member services, and all essential plan functions that contribute to the quality of member care, services, and experience. The QIP is reflective of the local health care delivery system and provides for a systematic approach to continuous improvement, encompassing the quality of evaluation and improvement activities across the continuum of health care services that impact members and providers. The following program components are essential in the promotion of quality health care delivery and plan services and are covered as part of the QI Program: Service Quality

• Complaints and Appeals Processes • Member Satisfaction (CAHPS®, Qualifying Health Plan [QHP] Enrollee Experience Survey, and

other) • Customer (member, producer, practitioner/provider, employer) Communications • Member Services


Integrated Clinical Management • Disease Management/Chronic Condition Management/Complex Case Management • Community Health Worker Program • Utilization Management • Pharmacy and Therapeutics • New Technology Evaluation

Population Health

• HEDIS® Measurement Set • CMS Quality Rating System • Continuity and Coordination of Care (Medical and Behavioral) • Culturally and Linguistically Appropriate Services • Wellness and Health Promotion • Patient Safety

Provider Network

• Network Management and Credentialing/Re-credentialing • Provider/Practitioner Satisfaction • Contracting: Provider/Practitioner • Accessibility and Availability

Plus:

• Delegation • NCQA Accreditation • QHP and Exchange Requirements


CREDENTIALING AND RE-CREDENTIALING NMHC is dedicated to providing our members with access to effective, high-quality, affordable health care. To ensure we maintain the highest integrity throughout our provider network, we verify and review the credentials of our participating practitioners and facilities initially, and again, every three years. This process helps us maintain and improve the quality of care and services delivered to our members. NMHC’s credentialing processes and standards have been designed to be consistent with broadly adopted standards, including NCQA and New Mexico statutory and regulatory requirements. NMHC prefers that physicians wishing to participate in the NMHC network are board-certified or board-eligible in their area of specialty; however, all practitioners applying for participation in the NMHC network must meet, at a minimum, the following NMHC eligibility criteria for initial credentialing and for re-credentialing:

• Current, valid, and unrestricted license to practice in the state in which the practitioner will treat NMHC members.

• For prescribing practitioners: Current and unrestricted Drug Enforcement Administration (DEA) registration and current unrestricted state Controlled Dangerous Substance (CDS) certificate, if applicable, in the state in which the practitioner practices. If a prescribing practitioner does not prescribe medications, he or she must submit a written description of a formal arrangement for medication prescription for his or her patients should any of them require medication.

• Graduation from medical school or professional school. • For physicians: Completion of residency program approved by the Accreditation Council for

Graduate Medical Education (ACGME). • For non-physicians: Completion of master’s degree and state mandated clinical hours, and

certification, if appropriate. • Current professional liability (malpractice) insurance. • For physicians and other practitioners with hospital privileges: Clinical privileges in good standing

at the facility designated by the practitioner as the primary admitting facility. If a practitioner does not have admitting privileges, he or she must submit a written description of a formal arrangement for inpatient coverage for his or her patients should any of them require hospitalization.

Credentialing Applications NMHC prefers the CAQH Universal Provider DataSource (UPD) application for gathering data about practitioners initially, and then every three years thereafter for re-credentialing. Practitioners are encouraged to update their online CAQH applications prior to credentialing or re-credentialing with NMHC. Credentialing/Contracting Providers who have not completed the credentialing process and have not been approved by the NMHC Credentialing Committee are considered Non-Contracted or “out of network” with NMHC. Claims for services rendered by Non-Credentialed, Non-Contracted providers may be denied payment.


Practitioners must have in their possession a signed agreement and the credentialing approval letter to begin to treat NMHC members. Practitioner Rights Related to the Credentialing Process Under Section 13.10.28 of the New Mexico Administrative Code (NMAC), providers have rights that include but are not limited to the following:

• Timely credentialing decisions • Reimbursement upon delay in the credentialing process • Payment of overdue claims and payment of interest due to delay in credentialing decisions • Payment dispute resolution

Physicians and other health care practitioners applying for participation in the NMHC provider network have the following rights regarding the credentialing process:

• The right to review the information submitted to support the credentialing application; • The right to correct erroneous information; and • The right to be informed of the status of the credentialing or re-credentialing application, upon

request.


PROVIDER ROLES AND RESPONSIBILITIES Primary Care Overview NMHC values the relationship between a patient and their Primary Care Practitioner (PCP) and believes access to PCPs is critical for the overall well-being of our members. The PCP plays a critical role in care management and the success of members who are encouraged to be engaged in their own health care maintenance and wellness. In our continuing efforts to offer affordable health care coverage, NMHC will work with our practitioners and members to avoid uncoordinated, episodic care by encouraging close relationships between the member and the PCP, and offering readily accessible preventive health care services and treatment. NMHC will also ensure that members with chronic health care needs have the information they need to manage their conditions. Primary Care Practitioner Selection NMHC encourages members to select a PCP within 30 days of enrollment onto one of our plans. NMHC will monitor for members that have not selected a PCP and conduct an outreach to the member to encourage PCP selection as soon as possible. Members are encouraged to call their intended PCP office and to establish with the PCP through a new patient visit. NMHC’s network of PCPs includes practitioners in the fields of family medicine, internal medicine, and pediatrics, including physician assistants and nurse practitioners practicing primarily in these areas of medicine. Other practitioners, such as OB/GYNs, may be considered for designation as PCPs if their scope of practice includes all aspects of primary care and they elect to practice in the role of a PCP. PCP designation for other specialists must be approved by the NMHC Medical Director. The member’s PCP will not be indicated on his or her ID card. Validation of the member’s eligibility can be completed through the Provider Portal, HealthXnet, or by calling Customer Care at 1-855-769-6642. Specialty Care Practitioners Specialty Care Practitioners are trained to provide services in specialized fields of medicine. To participate in our network, Specialty Care Practitioners must agree to accept patients from other in-network providers and to provide specialized services for the member. The table on the next page outlines the responsibilities of NMHC participating providers, whether PCP, Specialty Care, or Behavioral Health. In-Network Specialists Members may self-refer to in-network specialists. Prior authorization must be obtained for services requested for non-contracted providers.


Referrals to In-Network Providers Providers should always refer NMHC members to other in-network practitioners and facilities for care. Referring NMHC members to out-of-network providers often results in the out-of-network provider balance-billing our member. Special care should be taken to ensure that NMHC members are referred to in-network laboratories, radiology centers, hospitals, and other ancillary providers. A complete list of in network providers can be found on NMHC’s website at http://mynmhc.org/find_a_doctor.aspx or by clicking on “Find a Provider” from the home page. Referrals to Out-of-Network Providers In-Network providers should make best efforts to direct members to In-Network specialists. Authorizations for referrals to out-of-network providers must be obtained through NMHC and are subject to the prior authorization process.

Referring NMHC members to out-of-network providers always requires prior authorization. Responsibilities of NMHC Providers

Responsibility PCP Specialist MH/BH Meet NMHC’s credentialing and re-credentialing requirements. X X X Notify NMHC of changes that could affect the ability to effectively render medical care, including but not limited to changes in address, licensure, liability insurance coverage, and contracting status.

X X X

Refer to the NMHC provider contract for termination policies including time frame specifics and obligations. X X X

Adhere to NMHC utilization and quality management procedures. X X X Follow NMHC’s administrative policies and procedures including compliance with all Health Insurance Portability and Accountability Act (HIPAA) regulations.

X X X

Adhere to NMHC prior authorization procedures and requirements. X X X Ensure continuity of care for members by coordinating all care, referrals, and follow-up treatment of members. X

Initiate referrals to in-network specialty care providers, hospitals, and facilities as clinically appropriate. X X X

Provide medically necessary services to members who have been referred by their PCP, another in-network health care practitioner, or who have self-referred appropriately for specific health concerns, diagnoses, and treatments.

X X

Communicate with members, referring providers, and other in-network providers regarding services rendered, results, reports, and recommendations to ensure continuity and quality of care, including but not limited to prompt notification of abnormal test results.

X X X

Be aware of NMHC’s in-network participating providers, labs, Durable Medical Equipment (DME) providers, and other service providers in order to minimize delays, inconvenience, and billing problems for NMHC members.

X X X

http://mynmhc.org/find_a_doctor.aspx


Responsibility PCP Specialist MH/BH Maintain current medical records in accordance with state and federal regulatory requirements, and document communication with other providers in the member’s medical record.

X X X

Collect specified copayments and verify member eligibility and benefit certification for covered services. X X X

Confirm benefit eligibility from NMHC for non-emergent inpatient and outpatient services in accordance with the member’s benefit package. X X X

Agree to treat all patients equally, without discriminating on the basis of gender, age, ethnicity, sexual orientation, disability, race, religion, place of residence, health status, member status, income level, without regard to source of payment made for services rendered, or on any basis prohibited by federal or state law.

X X X

Respect the cultural and religious concerns of patients. Determine if members have any special cultural needs (e.g., concerns regarding blood or blood products, transplants, end-of-life care) special language needs, etc.

X X X

Report abuse or neglect of a child or vulnerable adult (revealed to a provider or suspected by a provider) to proper regulatory authorities pursuant to state law and contacting Children, Youth and Families at (505) 841-6100 or Statewide Central Reporting Intake at 800-797-3260.

X X X

Provide routine office visits (including evaluation, diagnosis, and treatment of illness and injury) and preventive health services in accordance with practice guidelines and medical policies.

X

Communicate with the other in-network referring providers regarding services rendered, results, reports and recommendations to ensure continuity and quality of care.

X X X

Guide members in self-management, goal setting and planning. X Guide members on how to use available health care services and treatment. X X X

Provide or arrange for the provision of services to designated laboratory, radiology, and pharmacy facilities. X X X

Provide health education services for members and their families. X X X Prescribe generic pharmaceuticals, where medically appropriate, and within NMHC’s formulary and formulary exceptions process. X X X

Administer injections, including adult and pediatric immunizations, in accordance with medical practice standards. X

Provide or arrange for the provision of medically related social services including behavioral health or chemical dependency. X X X

Inform patients of their right to know about all treatment options related to their conditions or disease processes, whether or not recommended services are covered benefits.

X X X

Maintain admitting privileges at a participating hospital within the service area or have a mechanism for admitting panel members. X X X


Responsibility PCP Specialist MH/BH Provide or arrange for the provision of covered services and telephone consultations during normal office hours and on an emergency basis, 24 hours a day, seven days a week.

X

When the PCP is unavailable, coverage should be arranged through a participating NMHC health care professional or with an on-call health care professional who has signed a coverage arrangement with a participating PCP.

X

Appointment Wait Times

• The wait time for an appointment with a Specialist shall not exceed four (4) weeks from time of the request.

• If provider is a PCP, he or she shall be available by telephone or by appointment twenty-four (24) hours per day, seven (7) days per week to ensure timely evaluation of members’ health needs.

• If the provider is unavailable, it is the responsibility of the provider to arrange for coverage by a NMHC network provider. The provider shall ensure that its wait times for appointments do not exceed the following:

o Routine, non-emergent appointments shall be scheduled as soon as is practical to the needs of the member but in no case longer than thirty (30) business days from request.

o Routine physical exams shall not exceed a wait time of four (4) months. o The wait time for urgent care appointments shall not exceed forty-eight (48) hours. o In a non-emergency situation, the wait time in the provider’s office shall not exceed thirty

(30) minutes from the scheduled appointment time.


MEDICAL MANAGEMENT Utilization Management Process The NMHC Medical Management Team evaluates requests for coverage in order to ensure that services rendered to members are medically necessary and/or appropriate, are occurring in the appropriate setting, and are included in the member’s benefit coverage. We utilize nationally recognized criteria (including InterQual®), evidence-based guidelines, and NMHC medical policies for clinical decision making. Utilization Management encompasses services rendered in ambulatory, inpatient, and transitional settings. Upon request, NMHC will provide a copy of the clinical rationale and medical criteria used to make a determination. There is no charge for this request. To obtain a copy, you may call our Medical Management Department at 1-855-769-6642, option 3, Monday through Friday, between 8:00 a.m. and 5:00 p.m., Mountain Time, or send a written request to: New Mexico Health Connections, P.O. Box 17874, Austin, TX 78760. Utilization management for the New Mexico Health Connections pharmacy benefit is managed by OptumRx®. Requests for pharmacy prior authorization can be faxed to OptumRx at 1-866-511-2202 or can be initiated by phone at 1-855-577-6550. See the Pharmacy section for additional details. Prior Authorization Prior authorization is the process of reviewing a requested medical service or item to determine if it is medically necessary and covered under the member’s plan. Prior authorization is part of the utilization management process and case management model. Determinations for medical appropriateness are made by evaluating information from the requesting physician, the member’s medical records, consultations, and relevant laboratory and radiological information. NMHC requires prior authorization for all elective hospitalizations, transfers to non-participating facilities, skilled nursing facility admissions, acute rehabilitation facility admissions, and advanced radiology services (CT, MRI, and PET scans). Prior authorization is also required for certain ambulatory services and DME. NMHC will make a determination for services where a prior authorization is required and will notify the member and the provider of the determination by phone and in writing. A standard (non-urgent) determination regarding prescription drugs will be made within three (3) working days, and five (5) working days for all other services of the receipt of request.

Please refer to the Prior Authorization List, located in the Forms section, for a complete list of services that require prior authorization. Concurrent Review Concurrent review is an extension of a previously approved ongoing course of treatment over a period of time or number of treatments. NMHC will make a determination if a concurrent approval is required


and will notify the member and provider by phone and in writing. The determination will be made within five (5) working days of the receipt of the request. Post-Service Review Post-service review is any review for care or services that have already been received, e.g., retrospective review. Post-service determinations include any requests for coverage of care or service that a member has already received. Determinations will be made within thirty (30) calendar days of receipt of the request. Expedited Review The expedited review will be conducted when NMHC determines, or when a provider indicates a delay would seriously jeopardize the member’s life, health or ability to attain, maintain, or regain maximum functions. The determination will be made within twenty-four (24) hours of the receipt of the request. This includes urgent pre-service and concurrent determinations. Adverse Determinations While all requests for services that require prior or concurrent authorization will be reviewed by an appropriate clinical professional, all adverse determinations will be referred to a NMHC medical director for an adverse determination decision. Prior to a formal appeal, providers may discuss the decision with the applicable NMHC medical director who made the adverse determination, which includes a peer-to-peer conversation around the clinical evidence involved in the case. Obtaining Authorization for Pre- and Concurrent Services For all services that require an authorization, the provider must contact the NMHC Medical Management department at 1-855-769-6642, option 3. Authorization requests may be phoned in to NMHC Medical Management during normal business hours, Monday through Friday, 8:00 a.m.to 5:00 p.m. MST, or faxed to 1-866-628-3047. If providers require assistance for urgent (expedited) determinations after business hours, please call 1-855-769-6642 to reach an on-call nurse case manager. Requests for authorizations must be made before the anticipated procedure, transfer, admission, or service is provided. Please include the following information in a Request for Authorization or for Concurrent Review for continued coverage of care:

• Member’s name and subscriber number • Scheduled date of procedure, transfer, admission, or service • Name of attending, referring, or ordering physician • Location of service and rendering physician • Diagnosis • Procedure • Supporting clinical/medical information for request


Please refer to the Prior Authorization Request Form located in the Forms section. For detailed information regarding determinations, please visit our Medical Management page at http://www.mynmhc.org/medical-management.aspx or contact us at 1-855-769-6642. Note: Due to circumstances regarding member eligibility and timeliness standards, an authorization is not a guarantee for payment. Prior authorization does not guarantee payment in cases of fraud and/or misrepresentation. Such cases may include the addition of procedures that were not originally authorized and/or information not originally provided. Case Management Program Case Management is a collaborative process that assesses, plans, implements, coordinates, monitors, and evaluates options and services to meet complex health needs of our members. Case Management is an integral part of NMHC’s Medical Management program because it allows us to partner with providers to prevent fragmented, episodic care for our members. Research and experience show that a higher-touch, member-centric care environment for at-risk members supports better health outcomes. Keys to Case Management are:

• Coordination • Monitoring of Service Delivery • Advocacy • Evaluation • Reassessment

NMHC is committed to the delivery of high-quality case management programs to our members. We place our members either into Level 1 Case Management or Complex Case Management. The level of case management is determined by an assessment of the member’s needs using an evidenced-based assessment tool, which develops a coordinated, member-focused, and multi-disciplinary plan of care. The plan of care is designed to meet the specific health needs of the member with the ultimate goal of helping members regain optimum health or improved functional capability, in the right setting and in a cost-effective manner. The NMHC Case Management program is available to all NMHC members. While NMHC monitors claims, utilization patterns, and other health plan data, we accept referrals into any level of case management from members, caregivers, discharge planners, nurse advice line staff, and providers. Levels of Case Management

• Level 1 Case Management • Complex Case Management

Level 1 Case Management Criteria (includes both medical and behavioral health Case Management)

• Recent, self-limiting, acute injury, or illness



• Exacerbation of a chronic condition, and may be at risk for complications or readmission • Inappropriate utilization of services such as repeated emergency department visits • Medication non-adherence

Complex Case Management Criteria

• Major organ transplant • Catastrophic illness • Multiple medical problems • Non-compliance or resistance to treatment • Inability to follow treatment plan • Repeated or unexpected readmissions • Members with multiple providers • Complex medical condition such as acute brain injury or respiratory failure • Complex psychosocial needs that are interfering with member’s ability to obtain appropriate

medical care Case Management Value to Providers The Case Manager:

• Obtains information about the home environment regarding barriers to recovery. • Evaluates family dynamics and the family’s impact on the patient’s response to the treatment

you have prescribed. • Assesses the member’s/family’s degree of motivation toward achieving optimal function. • Provides education on the member’s disease process. • Monitors progress towards treatment goals and the need for additional education and/or

clarification of information. • Explains and maximizes the member’s available health plan benefits. • Provides coordination of health care services. • Connects members with community resources.

Providers receive the following when their patients/NMHC members enroll in Case Management:

• Written or telephonic notification when a member who is the provider’s patient is enrolled in a Case Management program.

• A copy of the individualized care plan created for the member. • Communication from the Case Manager on the member’s progress toward goals.

Referral to Case Management To refer a member:

• By phone: Please contact Case Management at 1-844-691-9984. • By fax: Complete the Practitioner/Provider Complex Case Management Referral Form on

http://www.mynmhc.org/provider-resources.aspx and fax to 1-866-628-3047.



How to Contact Us • Phone: 1-844-691-9984 • Fax: 1-866-628-3047

Transition of Care If a member is receiving an ongoing course of treatment from a Non-Participating Provider when he/she enrolls in the Plan, or with a Participating Provider whose contract ends during a course of treatment, the member may be eligible to continue to receive services and have them covered by the Plan. This is called a Transition of Care. Determinations for Transition of Care are made based on established medical criteria. The Transition of Care Period will be for a period of no less than thirty (30) days. Transition of Care also applies to members who have entered the third trimester of pregnancy, including post-partum care directly related to the delivery. Disease Management NMHC is committed to supporting providers in the management of chronic conditions. NMHC Disease Management programs play an integral role in improving the quality of life and promoting cost effective outcomes for NMHC members with asthma and diabetes. Following are brief descriptions of the NMHC Asthma and Diabetes Disease Management programs: Asthma is a chronic disease that can be controlled with client education, medication management, and identification and elimination of asthma triggers in the environment. NMHC’s Asthma Management Program is designed to identify and improve clinical outcomes for our members with asthma, through the development and promotion of strategies that lead to better quality health care, cost effective outcomes, and higher member satisfaction. The program incorporates a structured process that defines goals, interventions, and outcome measures and provides guidance and focus for improvement. Interventions are based on best practices designed to address the obstacles and unique complexities that this vulnerable population faces and is consistent with the Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma, dated 2007, of the National Heart, Lung, and Blood Institute, adopted by NMHC in April 2013. The overall program goal is to control asthma by reducing impairment and risk, resulting in improved clinical outcomes and decreased health care costs. This goal is accomplished through:

• Proactively identifying members with asthma. • Analyzing and stratifying risks factors to determine which level of intervention member will

receive. • Outreaching, educating, and engaging asthmatic members and their families in interventions to

improve their health care outcomes and to develop asthma self-management strategies. • Facilitating communication, teamwork, coordination and management of necessary health care

services. • Assisting members requiring community resources such as transportation and food stamps.


Outcomes measures used to assess the effectiveness of the program include: • Reduction in asthma-related emergency room utilization. • Reduction in asthma-related inpatient hospital admissions. • Improvement in appropriate medication treatment for members with asthma. • Member program satisfaction and self-reported improvement in asthma management.

Diabetes is a chronic disease that can be controlled with client education, medication management, and identification and elimination of triggers in the environment. NMHC’s Diabetes Management Program (program) is designed to identify and improve clinical outcomes for our members with diabetes, through the development and promotion of strategies that lead to better quality health care, cost effective outcomes, and higher member satisfaction. The program incorporates a structured process that defines goals, interventions, and outcome measures and provides guidance and focus for improvement. Interventions are based on best practices designed to address the obstacles and unique complexities that this population faces, and are consistent with the American Diabetes Association, Diabetes Care, Standards of Medical Care in Diabetes, 2012 adopted by NMHC in April 2013. The overall program goal is to control diabetes by reducing impairment and risk, resulting in improved clinical outcomes and decreased health care costs. This goal is accomplished through:

• Proactively identifying members with diabetes. • Analyzing and stratifying risks factors to determine which level of intervention member will

receive. • Outreaching, educating, and engaging diabetic members and their families in interventions to

improve their health care outcomes and to develop diabetes self-management strategies. • Facilitating communication, teamwork, coordination and management of necessary health care

services. • Assisting members requiring community resources such as transportation and food stamps.

Outcomes measures used to assess the effectiveness of the program include:

• Reduction in diabetes-related emergency room utilization. • Reduction in diabetes-related inpatient hospital admissions. • Improvement in appropriate screenings such as low-density lipoprotein, hemoglobin A1c, and

microalbuminuria (dependent on available client data). • Member program satisfaction and self-reported improvement in diabetes management.

Referrals to the disease management program can be initiated by contacting the NMHC Medical Management department at 1-844-691-9984. For more information about NMHC Disease Management program, please call 1-844-691-9984. NMHC Care Connect Line NMHC has a nurse advice line available exclusively to NMHC members 24 hours per day, 7 days per week, 365 days per year. Experienced registered nurses answer questions and provide confidential


medical advice, at no cost. Nurses also refer callers to NMHC Case Management and Disease Management programs when appropriate. Members can call the NMHC Care Connect Line at 1-844-308-2552. Attestation Regarding Decision-Making and Compensation NMHC does not provide incentives for Care Management staff based on any utilization review decisions. All review decisions are based upon appropriate care and benefit coverage. Utilization Management Affirmation Statement Utilization management decision making is based only on appropriateness of care and service, and existence of coverage. There are no rewards to practitioners or other individuals for issuing denials of coverage, or requested services. There are no financial incentives for any utilization management decision makers that encourage decisions that result in underutilization. Initial or continued requests for treatment or length of stay may be approved by the designated Care Management Staff, based on the clinical information provided and reviewed against explicit criteria. All utilization adverse determinations/ denial decisions are made by Medical Directors.


PHARMACY NMHC offers a formulary or preferred drug list for all benefit plans. The NMHC pharmacy benefit is provided and managed by OptumRx, one of the industry’s largest and most experienced Pharmacy Benefit Managers (PBM). Pharmacy & Therapeutics Committee The NMHC formulary and the policies and procedures regarding managing the formulary are reviewed and approved by the NMHC Pharmacy & Therapeutics (P&T) Committee, which is comprised of actively practicing physicians, actively practicing pharmacists and other licensed health care professionals. P&T Committee members exercise their professional judgment in making determinations based on clinical and scientific evidence and analyses. The P&T Committee reviews the formulary and policies annually, and updates occur as information from the Food and Drug Administration (FDA), Centers for Medicare & Medicaid Services (CMS), or when sound clinical evidence becomes available. In its evaluation, review, guidance and clinical recommendations, the P&T Committee shall:

• Make recommendations on the therapeutic placement and appropriate prescribing guidelines for prescription drug products, and as appropriate, medical device products, intended for use in an ambulatory care setting.

• Provide ongoing review and monitoring of the safety, effectiveness, and quality of care of products contained within the formulary and in NMHC’s clinical programs.

• Initiate and/or review recommended DUR and DUE programs. • As necessary, review, advise, and approve utilization management guidelines, including prior

authorization, step therapies and quantity limits. • Advise NMHC on suitable educational programs (e.g., for health care provider networks, Plan

Participants, and pharmacy providers). • Make recommendations for the implementation of effective product utilization control

procedures. In addition to making clinical recommendations to the formulary, the P&T Committee shall provide information to medical, health care, and related pharmacy benefit professionals on matters pertaining to the clinical management of prescription drug and medical device usage by:

• Establishing policies and procedures to educate and inform health care professionals about products, product usage, and the P&T Committee’s clinical recommendations;

• Overseeing quality improvement programs that employ product use evaluation; • Providing recommendations for implementation of generic substitution and therapeutic

interchange programs based upon clinical and medical analysis and assessment; and • Evaluating, analyzing and reviewing protocols for the use of and access to non-formulary

products. Additional responsibilities may be established and delegated to the P&T Committee, as determined by the Chief Medical Officer.


NMHC Formulary The P&T Committee maintains the formulary for outpatient medications, which may be prescribed by any NMHC provider without Prior Authorization. NMHC providers are required to use formulary medications whenever medically appropriate. Specialty medications must be received from BriovaRx®. Pharmacists will not fill prescriptions for NMHC members for non-formulary drugs unless an approval has been received from OptumRx. Limits and quotas on drugs are set as needed by the P&T committee based on best medical evidence and communicated to providers through regular provider updates such as newsletters or other communications.

NMHC’s formulary AND formulary/utilization management updates are available on our website at http://www.mynmhc.org/Formulary.aspx. Formulary updates are posted as needed (as often as monthly). If you need assistance with the formulary or in obtaining

authorization, call OptumRx at 1-855-577-6550. Formulary exceptions are processed by OptumRx based on medical necessity. Covered medications include:

• Up to a 30-day supply of drugs requiring a prescription under state or federal law. • Up to a 30-day supply of drugs when purchasing through the mail order program. • Generic drug coverage at no cost for hypertension, depression, bipolar disorder, chronic

obstructive pulmonary disease, coronary artery disease, hypercholesterolemia, diabetes, congestive heart failure, asthma, and medications for oral chemotherapy.

• Specialty medications with prior approval. The prescription drug benefits for NMHC members are listed on the member ID card. For member convenience, we also offer a mail order prescription service for ongoing maintenance medications. Exclusions include but are not limited to:

• Non-prescription drugs • Compound medications • Medications excluded by regulation as described by the Centers for Medicare & Medicaid

Services (CMS) • Personal care items • Cosmetic drugs • Appetite suppressants, dietary supplements, prescription vitamins (other than prenatal), fluoride

products • Experimental drugs

Formulary Changes Participating practitioners may request the addition of a product to the formulary by submitting a request along with any supporting information to the NMHC Medical Management Team. The request will be presented at the subsequent P&T Committee for review and consideration. The P&T Committee decision will be provided to the requesting practitioner within fifteen (15) days following the P&T Committee meeting.

http://www.mynmhc.org/Formulary.aspx


Formulary Exceptions, Prior Authorizations, and Appeals All requests requiring approval for formulary exceptions should utilize the Drug Prior Authorization Request Form and should be faxed to OptumRx at 1-866-511-2202. Any questions can be directed to OptumRx at 1-855-577-6550. In all cases, the review and approval/denial of formulary exceptions will be executed as expeditiously as possible (but generally will not take longer than 48 hours). A provider requesting an exception should provide the following information:

• Patient’s name • Patient’s date of birth • Patient’s member ID • Medication requested • Name of pharmacy the patient accesses to fill prescriptions • Medical indication for request • Alternative medicines tried in the past • Provider contact information

Prospective review procedures and guidelines for formulary exceptions are developed and updated by and in conjunction with the NMHC P&T Committee and other specialist providers who have agreed to work with NMHC and OptumRx to provide expert guidance. In the event that a request for a coverage determination cannot be approved with the available clinical information, the prescriber, and the member are notified telephonically and in writing of the coverage determination. The written notification to the provider and the member will contain the rationale for the determination and a description of the appeal process. Additionally, the drug use by NMHC members is reviewed to determine if use is appropriate, safe, and meets current medication therapy standards. Providers may request copies of the criteria/guideline used to make decisions about formulary exceptions by calling OptumRx at 1-855-577-6550. The prescribed drug will be considered for coverage under the pharmacy benefit program when the following criteria are met:

• A formulary alternative is not appropriate for this patient (e.g., patient has a contraindication or intolerance to the formulary alternative, etc.); and

• The medication is being prescribed for an FDA approved indication OR the patient has a diagnosis that is considered medically acceptable in the approved compendia* or a peer-reviewed medical journal; and

• The patient does not have any contraindications or significant safety concerns with using the prescribed drug.

A lifetime approval will be granted for patients who meet the above criteria. If the patient does not meet the above criteria, the prescribed use is considered experimental/investigational for conditions not listed in this coverage policy section.


Generic Substitutions NMHC utilizes the OptumRx Essential Health Benefits formulary. When a new generic comes to market, the formulary is automatically updated. The brand-name equivalent drug will be removed from the formulary. NMHC will notify providers and members of these changes. Therapeutic Interchange A therapeutic interchange will only be made if a provider has received and approved a recommendation for a medication change. OptumRx does not automatically perform therapeutic interchanges. Site-of-Care Program NMHC partners with BriovaRx® Infusion Services on a site-of-care program. This program seeks to direct members from a higher-cost, less convenient site of care to a lower-cost, more convenient site of care. This program targets a limited number of infused medications used to treat chronic conditions. BriovaRx® Infusion Services has an ambulatory infusion suite in Albuquerque and can also offer at-home infusion options for NMHC members throughout New Mexico. Step Therapy OptumRx notifies NMHC of changes to all Utilization Management programs, including Step Therapy, on a monthly basis. NMHC will notify members who may be negatively affected by these changes. Online Tools NMHC members and providers are encouraged to use online tools available at https://campaign.optum.com/landing/rx/pharmacycareservices/members.html. Some actions a member or provider may perform online include:

• Determine copay or coinsurance amount for a medication • Initiate the exception process • Order a refill for an existing, unexpired mail order prescription • Locate in-network pharmacies • Determine potential drug interactions or side effects • Look for generic substitutes

*The approved compendia includes:

• American Hospital Formulary Service (AHFS) Compendium • Thomson Reuters (Health Care) Micromedex/DrugDex (not Drug Points) Compendium • Elsevier Gold Standard’s Clinical Pharmacology Compendium • National Comprehensive Cancer Network Drugs and Biologics Compendium

https://campaign.optum.com/landing/rx/pharmacycareservices/members.html


REIMBURSEMENT POLICY Reimbursement and Fee Schedules These policies apply to all NMHC plan products. The member’s contracted health plan benefits must be in effect on the date that services are rendered. NMHC reserves the right to review and update our Reimbursement Policies periodically. NMHC typically reimburses its providers based on the current CMS Medicare fee schedule. However, we may negotiate other reimbursement based on NMHC or provider needs. We may adopt reimbursement or methodology changes required by CMS guidance or federal or state laws/regulations, and we may incorporate annual CMS increases or decreases to the fee schedule. Although we primarily use the CMS fee schedule, we occasionally may process claims outside of the standardized CMS payment logic. The primary fee schedules are:

• CMS Inpatient Prospective Services (IPPS) • CMS Outpatient Prospective Services (OPPS) • Physician Fee Schedule (MPFS) • Durable medical equipment, prosthetics and orthotics, and supplies (DMEPOS) • CMS Clinical Laboratory Fee Schedule • CMS Average Sales Price (ASP) • Home Health PPS • Hospice PPS • Other applicable CMS fee schedules

To calculate your reimbursement, go to the easy-to-use CMS lookup tool: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PFSlookup/index.html.

This link will open in a new window. Enter a CPT or HCPCS code to calculate 100 percent of reimbursement. Be sure to apply your contracted allowable percentage, if applicable. In all cases, it is NMHC’s policy to reimburse providers the lesser of the provider’s billed charge or the provider’s contracted reimbursement rate. Reimbursement of Covered Non-Contracted Goods and Services It is NMHC’s policy to reimburse, rather than to deny claims payment to, contracted network providers when the provider submits claims for goods or services without a negotiated provision for those specific goods and services within the provider’s contract with NMHC. Reimbursement is contingent on the goods or services being a covered benefit, and contingent on the provider following NMHC guidelines for obtaining health plan authorization for the good or service, or providing the appropriate notification to the health plan prior to the service rendered. Providers must also treat members within their scope of practice specialty. The following are a few examples of covered non-contracted goods or services:

https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PFSlookup/index.html


• Durable Medical Equipment (DME) (goods) issued to a member without a negotiated DME

provision within the provider’s contract with NMHC. • Infusion drugs (goods and/or services) administered to a member without a negotiated provision

for drugs or “J” codes within the provider’s contract with NMHC. • Lab tests drawn and/or tested by provider or provider’s lab with no negotiated lab provision

within the provider’s contract with NMHC. While NMHC is not a CMS entity, NMHC will utilize the lesser of the provider’s billed charge, or CMS’s reimbursement methodology and fee schedules, to administer usual and customary payment for covered non-contracted goods and services. The following are examples of, but not limited to, the fee schedules NMHC uses use to administer payment of covered non-contracted goods and services:

• CMS DMEPOS: Durable Medical Equipment and Prosthetics and Orthotics • CMS ASP: Drugs, Infusion, Injectables • CMS CLFS: Clinical Laboratory Fee Schedule

Facility “Overhead” Reimbursement Policy While NMHC may utilize Medicare fee schedules and CMS methodology to adjudicate claims, NMHC is not a Medicare entity, and does not recognize or reimburse Facility Overhead Charges. A Facility Overhead Charge is a clinic charge for any technical component or overhead that is billed by a facility when a professional provider renders covered services to NMHC members in a facility clinic setting. NMHC defines a facility clinic visit as a preventive, curative, diagnostic, rehabilitative, and/or education service provided to an ambulatory patient in an outpatient setting, whether in a freestanding or attached facility that is either owned, operated, leased, or controlled by the facility. Some examples of a facility clinic visit include, but are not limited to a member:

• Having blood drawn for lab work at a facility draw station • Seeing a behavioral health provider on a hospital campus • Getting an X-ray at a diagnostic center • Seeing his or her PCP • Receiving education from a nutritionist

NMHC reimburses professional providers for covered services provided in a facility clinic setting when filed on a CMS-1500 form with place of service codes to include, but not limited to, place of service 11, 20, or 22 (Office, Urgent Care, Outpatient). This reimbursement will always include both the professional services and the associated overhead.


NMHC will not separately reimburse a facility for facility clinic visits and services billed on a UB-04, or any other form, when reported with revenue codes 510-525, 527-529 and any successor codes, including but not limited to the accompanying G Codes. The technical and overhead component of the facility clinic visit will be included by NMHC in the reimbursement paid to the professional provider for professional services, as reported on the CMS-1500 form, with place of service codes to include, but not limited to, place of service 11, 20, or 22. These services may encompass but are not limited to Evaluation and Management health care services provided to NMHC members in a clinic setting. The facility may not seek reimbursement for any technical or overhead component of the clinic charge from NMHC or from our members. The member is held harmless and may not be balance-billed by the provider for clinic facility charges. In accordance with the terms of your Agreement with NMHC, we reserve the right to recover overpayments resulting from separately billed clinic/facility fees billed in combination with a professional office/clinic visit claim. Find out more about NMHC’s reimbursement policies and procedures on our website at http://mynmhc.org/provider-reimbursement-policy.aspx.

http://mynmhc.org/provider-reimbursement-policy.aspx


CLAIMS SUBMISSION AND PAYMENT NMHC has implemented claims program requirements to ensure timely and accurate processing of claims for our participating providers. Members are also required to follow the applicable requirements of their plan to receive benefits. Member Eligibility and Benefits Providers must verify that a patient is an eligible member of the Plan and should verify benefits prior to rendering services. NMHC encourages providers to verify a member’s eligibility status throughout the period of continued and/or extended services as eligibility may change at any time. It is not uncommon for retroactive terminations to occur, which may affect the status of a member’s eligibility. For this reason, verification of eligibility is not a guarantee of payment. Provider offices should consider the following as a guide to help obtain verification of eligibility and benefits:

• All NMHC members must present their ID card at the time of service. Providers should further verify eligibility and benefits. Providers can use the link to the Provider Portal from our website at http://www.mynmhc.org/my-account-login.aspx.

• Providers should review the Prior Authorization Requirements prior to rendering services to determine whether or not prior authorization is required.

• Collect the member’s cost-sharing requirement at the time of service. Billing Members for Services Providers should not bill members for any covered services, except for applicable copays, deductibles, and/or coinsurance amounts. Members may not be billed for services due to a provider’s failure to obtain required authorizations. Any deductibles and/or coinsurance and charges for non-covered services should be billed to the member following the receipt of the Explanation of Payment (EOP) from NMHC. Providers should not require payment from a member for any non-covered service that the member receives, unless the member is informed that the services are non-covered and has agreed in writing, in advance of receiving the services, to pay for such services. A member informed by the provider that care is potentially non-covered, and proceeds with receiving the potentially non-covered service, may not be billed for the non-covered service by the provider, unless the member has previously agreed in writing to pay for the service. Any waivers signed by the member must be specific as to the details of the excluded or non-covered service and its cost. General agreements to pay, such as those signed by the member at the time of service, are not evidence that the member knew specific services were excluded or excludable or that the member agreed to pay.

http://www.mynmhc.org/my-account-login.aspx


Claims Submission Providers are required to submit clean claims for any services rendered to NMHC members. NMHC is required to process clean claims within thirty (30) days of receipt for electronic submissions, and forty-five (45) days for paper submissions. Providers will receive an Explanation of Payment (EOP) for all claims received. A clean claim is a manually or electronically submitted claim that:

• Contains substantially all the required data elements necessary for accurate adjudication in accordance with the terms and conditions of the applicable plan and without the need for additional information;

• Is not materially deficient or improper, including lacking substantiating documentation currently required by the payor;

• Presents no mitigating or unusual circumstances (including the need for current coordination of benefits information) that prevent payment from being made in accordance with required time-frames; and

• Is submitted within NMHC’s timely filing requirements. Accurate and timely submission of claims for billing is a critical component to a provider’s compensation. Additional tips for submitting claims are:

• Submit clean claims on a CMS-1500 form or UB04 form that is compliant with the National Provider Identifier (NPI) and Health Insurance Portability and Accountability Act (HIPAA) regulations. Valid CPT, Revenue, HCPCS, ASA, and ICD-10 codes must be used and include appropriate modifiers, if applicable.

• Clean claim example includes the information listed on the attached link below. We may require additional information for particular types of services, or based on particular circumstances or state requirements.

• While some claims may require supporting information for initial review. NMHC will request additional information when needed.

For questions about claims, filing, or contracted reimbursement, please contact NMHC’s Customer Care center at 1-855-769-6642. Time Frame for Filing Claims

• Claims must be submitted no later than ninety (90) days after the provision of covered services. • In cases in which NMHC is the secondary payor, claims must be filed ninety (90) days from the

date of service or ninety (90) days from the date that the Provider receives notice of payment decision from the primary payor, whichever is later.

Only those charges for Covered Services billed in accordance with NMHC’s standard claim coding and bundling methodology will be considered for payment. The Plan reserves the right to “re-bundle” billed charges that have been unbundled and to review claims for medical necessity determination prior to


payment. Only services that are medically necessary and covered by the plan will be considered for payment. Providers must submit a claim for your services, regardless of whether you have collected the copayment, deductible, or coinsurance from the member at the time of service. Electronic Claim Submission NMHC understands how important it is for claim submissions to be processed timely and accurately. The quickest and most efficient way to file claims is electronically. If your office is not currently submitting claims electronically, we encourage you to do so. Electronic claim submission offers a number of benefits for a provider’s office, including:

• Streamlined billing, which helps reduce paperwork; • Faster claim delivery to NMHC instead of traditional mail delivery time; • Improved feedback/correction capability for claims with missing or invalid data; • One address for all NMHC claim submissions; • Receipt acknowledging proof of acceptance by NMHC; and • Quicker response/payment time for claims.

NMHC uses Change Healthcare as its clearinghouse. Providers should work with their clearinghouses to ensure they can file to Change Healthcare.

NMHC Payer ID: 45129 Paper Claims Submission Although NMHC highly recommends filing claims electronically, provider offices can help timeliness and accuracy of paper claims filing by adhering to the following guidelines when completing and submitting paper claims:

• Use the current CMS-1500 or the current UB04 claim form as appropriate when submitting paper claims that are compliant with the National Provider Identifier (NPI) and HIPAA regulations. Generally, the CMS-1500 form is used for professional services and the UB04 is used for facility services. Please use original claim forms as opposed to copies of the forms.

• Make sure that all the fields are completed accurately. This will help avoid returned claims due to missing information.

• Refer to the member’s current identification (ID) card to help ensure you have the appropriate member ID number as well as the correct address for submitting claims.

• Use machine/computer generated printed forms. NMHC will not accept hand written claims. • Claims with altered information or markings will not be accepted for consideration. • When submitting attachments or documents that are to be considered as part of the claim

processing, please include the member’s ID number.


All paper claims must be submitted to: New Mexico Health Connections P.O. Box 211468 Eagan, MN 55121 Claims Coding Industry standard will be applied to claims based on:

• CPT definitions or guidance • CMS guidance (including, but not limited to Correct Coding Initiatives [CCI]) • Specialty society guidance • Clinical consultant network – industry/specialty-specific subject matter experts • Health Plan Policy (HPP) – Health Plans concur that these edits are consistent with current health

plan policies. It is not uncommon for CPT-4, Revenue, HCPCS, and/or ICD-10-CM codes to be added, deleted, or modified. Providers are encouraged to keep track of such changes and ensure that claims are submitted with valid codes. Any claims submitted with invalid CPT-4, HCPCS, or ICD-10-CM codes may be rejected for payment. ICD-10-CM codes requiring fourth and fifth digits must be indicated on claims. Additionally, appropriate modifiers should be included on claim submissions when applicable. When a miscellaneous code must be used to identify a procedure, providers must include an explanation and/or the surgical procedure or operative notes supporting the use of the code. For miscellaneous or temporary pharmaceutical codes, providers must include the NDC number, drug name, and dosage and/or a copy of the invoice in order for the claim to be considered for payment. Checking Claims Status NMHC is required to process clean claims upon receipt within thirty (30) days for electronic submissions and forty-five (45) days for paper submissions. Providers will receive an Explanation of Payment (EOP) for all claims received. Claims may be rejected or be returned to the provider prior to acceptance into our claims system. Various reasons may cause this to occur; the most common being incomplete claims, invalid codes, electronic clearinghouse problems, or claims sent to the wrong address. NMHC recognizes that there are a variety of reasons that may prevent a claim from entering the claims system to be processed. Therefore, if a provider submits a claim to NMHC and NMHC has not provided an EOP within the timeframes stated above, it is important for the provider to follow up with NMHC to check status of the claim(s) in question. Claims that are not followed up by provider within required time periods will not be processed for payment. Providers should follow up at least every 30 days when checking status of any outstanding claims to ensure that both NMHC and providers identify and communicate issues preventing processing are resolved timely, so claims may be processed.


Any claims submitted outside the timely filing requirements as noted above will not be considered for payment unless the provider has documented proof of timely follow-up at least monthly from the date claim was submitted to NMHC. Providers can verify claim status with NMHC in the following ways:

• Log in to the Provider Portal at http://www.mynmhc.org/my-account-login.aspx. • Complete and fax the NMHC Claims Inquiry Form to (312) 548-9943. • Contact NMHC Customer Care to check the status of claims. Customer Care can be reached 8:00

a.m. to 5:00 p.m. MST at 1-855-769-6642. Calls are limited to five (5) claims inquiries per call. The most common claim submission errors are as follows:

• Missing, expired or misused, CPT, ICD-10, HCPCS, or Revenue codes; • No Explanation of Benefits (EOB) submitted when the member has other insurance coverage or

Medicare primary coverage; • Missing anesthesia time; • Itemized statement is not attached; • Missing place of service, type of service, or bill type; • Incorrect or missing member ID number; • Missing NPI number (Rendering and/or Billing); and • Incorrect date of birth for the patient.

Reassessments/Adjustment Requests It is the responsibility of the provider offices to immediately post/track all claim payments and/or denials based on the Explanation of Payment (EOP) provided. It is not uncommon for a provider to request reassessment or adjustment following the processing of a claim(s). There are a variety of reasons that providers may request a reassessment or adjustment. Some examples included are:

• Corrected claims • Proof of timely filing • Calculation of units billed • Claim was submitted and paid twice • Claim was paid at the wrong rate (contractual) • Claim was paid for the wrong date(s) of service(s) • Claim was paid at a wrong level of care • Services were span billed with overlapping days on more than one claim • A compliance audit was conducted • Post payment recoveries • Authorization was not applied accurately

However, regardless of the reason for the reassessment or adjustment request, providers must comply with the following timeframes and processes when submitting these requests:

http://www.mynmhc.org/my-account-login.aspx


• The request must be made within twelve (12) months after the date the claims were originally paid or the date NMHC discovered the overpayment.

• Requests for reassessment and adjustments can be made to Customer Care, 8:00 a.m. to 5:00 MST, at 1-855-769-6642.

• Providers are strongly encouraged to utilize the Claim Reassessment/Adjustment Request Form. Please refer to the Forms section for a copy of this form.

Corrected claims are handled as indicated below:

• Electronic adjustments for corrected claims – Service Loop CLM 05/03 Frequency Field “7” (I – Institutional or P – Professional) – this indicator will allow for an electronic claim adjustment.

• Paper – Providers file CMS-1450 or CMS-1500 paper forms to P.O. Box 211468, Eagan, MN 55121. Providers must include any of the required/supporting documentation such as EOB, Original Paper Claim Form, and Clinical Documentation (if applicable).

Coordination of Benefits Occasionally, claims for services rendered to members are the primary responsibility of other payors. Providers are requested to assist NMHC to maximize recoveries under coordination of benefits or subrogation and bill services to the responsible primary payor. For coordination of benefits, NMHC requires an explanation of payment (EOP) from the primary payor before considering payment of claims when we are secondary. If the EOP is not attached, the claim will be denied with the request of this additional information. In cases in which NMHC is the secondary payor, claims must be filed ninety (90) days from the date of service or ninety (90) days from the date that the Provider receives notice of payment decision from the primary payor, whichever is later. Please attach a copy of the primary payor’s EOP to the submitted claim. EOPs are also required for services denied by the primary payor and should be submitted to NMHC for consideration. Any claims submitted without the primary payor’s EOP will be denied with a request for the additional information. NMHC follows the National Association of Insurance Commissioners (NAIC) Coordination of Benefits Model rules in determining which payor’s plan is primary and which is secondary. Subrogation NMHC conducts subrogation investigations for services that may indicate third party liability. When the member or provider receives money to compensate for medical or hospital care for injuries or illness caused by another party, NMHC must be reimbursed for any expenses that we may have paid in connection to the incident. If the member or provider does not seek damages, the provider must agree to allow NMHC to attempt recovery. For more information regarding subrogation policies and procedures, please contact Customer Care at 1-855-769-6642.


FRAUD AND ABUSE NMHC’s Fraud and Abuse Program is overseen by the Chief Compliance Officer or his/her designee. The Program seeks to:

1. Prevent, detect, and investigate all forms of health insurance fraud; 2. Educate appropriate employees and other persons on fraud detection and the Company’s anti-

fraud plan; 3. Cover reports of insurance fraud to appropriate law enforcement and regulatory authorities; and 4. Pursue restitution, where appropriate, for financial loss caused by insurance fraud.

Definitions Fraud is defined as “any type of intentional deception or misrepresentation made by an entity or person with the knowledge that the deception could result in some unauthorized benefit to the entity or him/her or some other person in a managed care setting.” It includes any act that constitutes fraud under applicable federal or state law. Fraud may be found under the following conditions (the following list is intended as an example and not as a limitation):

• When a provider submits a bill for a service that was not provided; or • When a provider bills for a time period greater than the time actually spent with the client; or • When a provider bills for the provision of a service that did not meet the service definitions,

performance specifications, state or federal regulations, or accreditation standards customarily recognized in behavioral health care; or

• Inappropriate or frequent referrals that may constitute a conflict of interest; or • Authorizations for services to providers who may have personal or other financial relationships

with care managers; or • Other related claims or care management issues that may involve intentional deception or

misrepresentation as referenced above. Waste is defined by the OIG as the intentional or unintentional, thoughtless or careless expenditure, consumption mismanagement, use, or squandering of government resources to the detriment or potential detriment of government programs. Waste also includes incurring unnecessary costs as a result of inefficient or ineffective practices, systems, or controls. Abuse is defined as “any practices that are inconsistent with sound fiscal, business, or medical practices, and result in unnecessary cost to NMHC, or in reimbursement for services that are not medically necessary or that fail to meet professionally recognized standards or contractual obligations for health care in a managed care setting.” It also includes recipient practices that result in unnecessary cost to NMHC. Examples: Altering claims, double billing, billing for services not provided, over-utilization; kickbacks, using fraudulent credentials and pharmacies billing for brand when generic drugs are dispensed.


Federal and State Statutes and Regulations Applicable to NMHC Providers: • The New Mexico Insurance Fraud Act (59A-16C NMSA) • The False Claims Act (31 U.S.C. 3729-3733) • The Anti-Kickback Statute (42 U.S.C. 1320a-7b(b) and 42 C.F.R. 1001.952) • The Physician Self-Referral Law (42 U.S.C. 1395nn and 42 C.F.R. 411.350) • The Exclusion Authorities (42 U.S.C. 1320a-7; 1320c-5 and 42 C.F.R. 1001 and 1002) • The Civil Monetary Penalties Law (42 U.S.C. 1320a – 7a and 42 C.F.R. 1003) • The Health Care Fraud Statute (18 U.S.C. 1347 and 1349) • The Patient Protection and Affordable Care Act

Reporting Potential Fraud, Waste, and Abuse and Other Suspicious Activity Reports are confidential. When reporting suspicious behavior, you may remain anonymous. To report:

• Contact our Fraud, Waste, and Abuse hotline: 1-855-882-3903, or (505) 492-2058, extension 156 • Download our Fraud, Waste, and Abuse Report form from the Member Forms section of our

website at http://www.mynmhc.org/forms-2.aspx and fax it to 1-866-231-1344 • Write to us:

New Mexico Health Connections ATTN: Compliance/FWA P.O. Box 36719 Albuquerque, NM 87176

http://www.mynmhc.org/forms-2.aspx


CONTRACTED PROVIDER APPEALS AND GRIEVANCES NMHC takes provider and practitioner appeals and complaints (grievances) seriously. Complaints are an important mechanism for identifying concerns and dissatisfaction within our provider network. Provider grievances and appeals are processed to ensure a timely and thorough investigation and according to federal and/or state regulatory requirements. Contracted Provider Grievances Regarding NMHC’s Plan of Operation NMHC processes and responds to provider grievances in accordance with the requirements outlined in the New Mexico Administrative Code, 13.10.16. A provider or practitioner may file a grievance regarding their concern with any aspect of NMHC’s Plan of Operation, including concerns regarding quality of and access to health care services, the choice of health care providers and the adequacy of NMHC’s provider network; or, the existence of adequate cause to terminate a provider’s participation with a managed health care plan to the extent that the relationship is terminated for cause. If a provider has a concern regarding the operation of the plan, with, he/she may request in writing that the concern be reviewed by the NMHC Provider Reconsideration Committee. This committee shall consist of management and/or staff from various departments within THNM such as the Director of Provider Services, Director of Claims and Enrollment, and a NMHC Medical Director. The Reconsideration Committee reviews a provider’s written grievance and sends a written response within twenty (20) business days after NMHC obtains all necessary and pertinent information. Providers may file a grievance by:

• Calling the Customer Care Center at 1-855-769-6642 • Faxing us at: 1-800-747-9132, ATTN: Appeals & Grievances • Writing to us:

New Mexico Health Connections ATTN: Appeals & Grievances P.O. Box 36719 Albuquerque, NM 87176

Review of Provider Grievances by the New Mexico Office of Superintendent of Insurance (OSI) Following this internal review, if the provider remains dissatisfied with the result of the internal appeal and grievance process, he/she may file a complaint with the OSI. The provider must file a written request with the OSI within thirty (30) days from receipt of the written decision of the NMHC Provider Reconsideration Committee. Please contact us at 1-855-7MY-NMHC (1-855-769-6642) for detailed information regarding our Provider Grievance program.


Contracted Provider Appeals For appeals challenging the denial of a claim in whole or part, providers must file an appeal request within 180 days from the date of the initial Explanation of Payment (EOP) denial. Appeals must be submitted in writing, following claims processing and receipt of a formal denial from NMHC. NMHC allows contracted providers 2 levels of appeal review. Appeals requests are reviewed and a determination made within 60 days from the date of receipt by NMHC. If a provider is not satisfied with the outcome of the initial appeal review, the provider may request a level 2 appeal review. The provider must file the request for a level 2 appeal review within thirty (30) days of the date of the level 1 decision. Requests received after the thirty-day time period are not eligible for further review. Please review the Reassessments/Adjustment Requests section of the Claims Submission and Payment section of this handbook to determine if non-payment requires a reassessment or adjustment request or filing a formal, written appeal. Claim reassessment/adjustment requests submitted as appeals will be returned to the provider to submit via the appropriate claim reassessment/adjustment process. Providers may file a written appeal by:

• Faxing us at 1-800-747-9132, ATTN: Appeals & Grievances • Writing to us:

New Mexico Health Connections ATTN: Appeals & Grievances P.O. Box 36719 Albuquerque, NM 87176

Appeal Process for Provider Terminations Through a variety of sources, NMHC may discover that a practitioner is not meeting the standards of providing reliable, safe, quality care to his or her patients who are NMHC members. In these circumstances, there is a range of actions NMHC may pursue to ensure the provision of safe and effective care, including review of the practitioner’s current status with a variety of Boards or oversight bodies (e.g., the New Mexico Board of Medical Examiners), the implementation of a corrective action plan to address the documented performance deficiency, or even the removal of the practitioner from the network, the latter referred to as “termination for cause.” Providers should note that NMHC is required to notify appropriate authorities when it acts to limit, suspend, or terminate a practitioner’s participation in the network. NMHC does offer a practitioner the opportunity to appeal such adverse participation decisions. For a variety of reasons, NMHC may end its contractual relationship with a provider solely based on business needs, referred to as “termination without cause.” Terminations without cause may include the periodic removal of a practitioner from the NMHC network when there are more practitioners than needed to meet NMHC’s accessibility and availability standards. Such terminations are not related to practitioner performance, quality of care or service, or a material breach of contract. Nor are terminations without cause subject to an appeal process.


For detailed information regarding our policy and procedures regarding provider terminations, please visit our website at http://www.mynmhc.org/provider-grievances-appeals.aspx or contact us at 1-855-769-6642.

http://www.mynmhc.org/provider-grievances-appeals.aspx


MEMBER COMPLAINTS AND APPEALS NMHC takes member complaints, in the form of grievances and appeals, seriously. Complaints are an important mechanism for identifying concerns and dissatisfaction among our membership. Member grievances and appeals are processed to ensure a timely and thorough investigation and according to federal and/or state regulatory requirements, as well as accreditation standards of the National Committee for Quality Assurance (NCQA). Members have the right to file an appeal if they disagree with a NMHC decision to deny a service, in whole or in part. Members may also file a grievance related to our administrative practices, such as those decisions that appear to affect the availability, delivery or quality of health care services, including but not limited to claims payment or termination of coverage. A complaint may be filed by a member or another person authorized to do so by the member. The member should initially contact the Customer Care Center at 1-855-769-6642. A Customer Care Center representative will make every effort to resolve the member’s complaint to his or her satisfaction the first time it is brought to our attention. If the Customer Care Center representative is unable to resolve the concern or Complaint to the Member’s satisfaction, the Member can request that a formal appeal or grievance be filed. If a member exhausts the appeal or grievance process, he/she has the right to request an external independent review by the New Mexico Office of Superintendent of Insurance. For detailed information regarding member grievances and appeals, visit our Member Rights and Responsibilities page on our website at http://mynmhc.org/member-rights-and-responsibilities.aspx or contact us at 1-855-769-6642.

http://mynmhc.org/member-rights-and-responsibilities.aspx


MEMBER RIGHTS AND RESPONSIBILITIES As a Member of this Plan, you are entitled to certain rights when you access coverage. There are also certain responsibilities that you hold. It is important that you understand these rights and responsibilities. As a Member of this Plan, you have the following rights: • You have a right to detailed information about your Plan. This may include benefits and services that

are covered or excluded from the Plan, and all requirements that must be followed for Prior approval and Utilization Review.

• You have a right to always have available and accessible services for Medically Necessary and covered services; including 24 hours per day, 7 days per week for urgent and emergency care services, and for other health care services as defined by the Evidence of Coverage or the Summary of Benefits and Coverage.

• You have a right to information about your out-of-pocket expense limitations, and an explanation of your financial responsibility for services provided to you.

• You have a right to be treated in a manner that respects your privacy and dignity. • You have a right to participate with your Providers in making decisions about your health care. • You have a right to receive an explanation of your medical Condition, recommended treatment, risks

of the treatment, expected results, and reasonable medical alternatives from your Provider in a language that you understand, regardless of cost or your plan’s benefits.

• You have a right to be informed about your treatment from your Participating Provider; to request your consent (agreement) to the treatment; to refuse treatment, including medication; and to be told of the possible consequences of refusing such treatment. This right exists even if treatment is not a covered benefit or Medically Necessary according to the Plan. The right to consent or agree to treatment may not be possible in a medical emergency where your life and health are in serious danger.

• You have a right to voice Complaints, Grievances, or Appeals with the Plan or its regulatory bodies about the Plan and/or the care that we provide.

• You have a right to make recommendations regarding the Plan’s Member Rights and Responsibilities policies.

• You have a right to receive assistance in a prompt, courteous, and responsible manner. • You have a right to the confidential handling of all communication and information maintained by

the Plan. Your written permission will always be required for the release of medical and financial information, except: • When clinical data is needed by health care Providers for your care; • When the Plan is bound by law to release information; • When the Plan prepares and releases data but without identifying Members; and • When necessary to support the Plan’s programs or operations, including for payment and to

evaluate quality and service. • You have a right to be promptly informed of termination or changes in benefits, services, or

Participating Providers.


• You have a right to know, upon request, of any financial arrangements or provisions between the Plan and its Participating Providers, which may restrict referrals or treatment options or limit the services offered to you.

• You have a right to receive an explanation of why a benefit is denied; the opportunity to appeal the denial decision; the right to a second level of appeal with the Plan; and the right to request help from the New Mexico Superintendent of Insurance.

• You have a right to adequate access to health care providers near your home or work within the Plan’s service area.

• You have a right to receive detailed information about requirements that you must follow for prior approval of certain services.

• You have a right to have access to a current list of Participating Providers in the Plan’s network. • You have the right to an example of the financial responsibility incurred by a Covered Person for

services received from an Out-of-Network or Non-Participating Provider. • You are responsible for learning how your Plan works. You should carefully read and refer to your

Member Handbook and your Summary of Benefits and Coverage. Contact the Customer Care Center if you have questions or Concerns about your Plan.

As a Member of the Plan, you have the following responsibilities: • You have a responsibility to provide honest and complete information to the Plan and to your

Providers. • You have a responsibility to read understand the information that you receive about your Plan. • You have a responsibility to know the how to properly access coverage and utilize your Plan. • You have a responsibility to understand your health problems and participate in developing

treatment goals that you agree to with your Providers. • You have a responsibility to follow plans and instructions for care that you have agreed to with your

Providers. • You have a responsibility to present your Plan ID card before you receive care. • You have a responsibility to promptly notify your Provider if you will be delayed or unable to keep an

appointment. • You have a responsibility to pay your applicable Deductible, Copayment, and Coinsurance amounts,

including those for missed appointments. • You have a responsibility to express your opinions, Concerns or Complaints in a constructive way to

the Plan or to your Provider. • You have a responsibility to inform the Plan and/or your Employer of any changes in family size,

address, phone number or Membership status within thirty (30) calendar days of the change. • You have a responsibility to make Premium payments on time if they are not paid directly by your

Employer. • You have a responsibility to notify the Plan if you have any other insurance coverage. • You have a responsibility to follow the Plan’s Complaints and Appeals process when you are

dissatisfied with the Plan or a Provider’s actions or decisions.


FORMS AND OTHER RESOURCES The material contained in this section is for your reference.

• Individual Benefit Plans • Prior Authorization List • Sample ID Cards • Claims and Eligibility Quick Reference Guide • Online Provider Directory Guide • Notice of Privacy Practices • Frequently Asked Questions • Prior Authorization Request Form • Claims Inquiry Form • Claims Reassessment/Adjustment Request Form • Blank CMS-1500 Claim Example and Instructions • Blank UB-04 Claim Example and Instructions

http://www.mynmhc.org/individual-plan-documents.aspx

http://www.mynmhc.org/prior-authorization-requests.aspx

http://www.mynmhc.org/id-cards.aspx


http://www.mynmhc.org/find_a_doctor.aspx

https://www.mynmhc.org/protecting-your-privacy.aspx

http://www.mynmhc.org/Frequently_Asked_Questions_2.aspx




http://www.mynmhc.org/uploads/files/Health%20Care%20Professionals/CMS-%201500%20Blank%20Paper%20Claim%20Form%202-7-14.pdf

http://www.mynmhc.org/uploads/files/Health%20Care%20Professionals/Clean%20Claim%20UB%202-7-14.pdf

New Mexico Health Connections Individual and Family HMO Plans for 2019 This benefit grid contains plan highlights only and is subject to change. Specific terms of coverage are listed in the Summary of Benefits and Coverage and the Evidence of Coverage (Member Handbook), including plan limitations and exclusions.

NMHC-PD0136-0818

Care Connect Gold Plus HMO

Care Connect Gold Essential HMO

Care Connect Silver Plus HMO

Care Connect Silver HMO

Care Connect Silver HDHP HMO

Care Connect Bronze Plus HMO

Care Connect Bronze Essential

HMO

Care Connect Bronze HDHP

HMO

Care Connect Catastrophic

HMO7

Annual In-Network Deductible $500 individual $1,000 family

$2,000 individual $4,000 family








Coinsurance after Deductible1 30% 30% 40% 40% 0% 50% 50% 0% 0%

Annual Out-of-Pocket Maximum2 $7,900 individual $15,800 family









Preventive Care Services3 No charge No charge No charge No charge No charge No charge No charge No charge No charge

Primary Care $25/visit $25/visit $35/visit $50/Visit 0% $50/visit 50% 0% $0 first 3 visits, then 0%

Specialist Care $50/visit $50/visit $80/visit $80/visit 0% $100/visit 50% 0% 0% Outpatient Behavioral Health Visits No charge $25/visit No charge $50/visit 0% $50/visit 50% 0% 0%

Urgent Care $50/visit $50/visit $50/visit $80/visit 0% $100/visit 50% 0% 0% Emergency Room Services $350/visit $500/visit $1,000/visit 40% 0% 50% 50% 0% 0%

MRI/CT/PET 30% (ded. does not apply)

30% (ded. does not apply)

40% (ded. does not apply) 40% 0% 50% 50% 0% 0%

PT/OT/ST4 $50/visit $50/visit $80/visit $80/visit 0% 50% 50% 0% 0% Outpatient Hospital 30% 30% 40% 40% 0% 50% 50% 0% 0% Inpatient Hospital 30% 30% 40% 40% 0% 50% 50% 0% 0%

Lab and X-Ray Services $10 lab $30 x-ray

$10 lab $50 x-ray

$30 lab $100 x-ray

$30 lab $100 x-ray 0% 50% 50% 0% 0%

Preferred Generic Drugs5 No charge No charge No charge No charge 0% No charge No charge 0% 0% Generic Drugs5 $10/Rx $25/Rx $25/Rx $25/Rx 0% $50/Rx 50% 0% 0%

Brand-Name Drugs $30/Rx $75/Rx $75/Rx $75/Rx 0% $80/Rx 50% 0% 0% Non-Preferred Brand Drugs $150/Rx $150/Rx 40% 40% 0% 50% 50% 0% 0% Preferred Specialty Drugs 40% 40% 40% 40% 0% 50% 50% 0% 0%

Non-Preferred Specialty Drugs 50% 50% 50% 50% 0% 50% 50% 0% 0% Pediatric Vision6 No charge No charge No charge No charge 0% No charge No charge 0% No charge

1. All coinsurance percentages are after deductible unless specified otherwise. 2. Annual Out-of-Pocket Maximum includes the Deductible, Copayments, Coinsurance, and prescription drug costs. 3. Cost-share may apply for services received during visits that are not related to Preventive Care, such as Primary Care, Specialist Care, or Emergency Room Services. 4. PT/OT/ST are therapy services. PT = Physical Therapy, OT = Occupational Therapy, ST = Speech Therapy. 5. NMHC offers medications at a $0 copay for many chronic conditions on most plans (excluded Individual plans are Care Connect HDHP Silver, Care Connect HDHP Bronze, and Care Connect Catastrophic). The $0 copay applies to certain generic medications received

from a participating pharmacy for the following chronic conditions: asthma, bipolar disorder, chronic obstructive pulmonary disorder (COPD), congestive heart failure (CHF), coronary artery disease, depression, diabetes, hypercholesterolemia (high cholesterol), hypertension (high blood pressure), and for oral chemotherapy medications. Please refer to the NMHC Formulary Reference Guide (Drug List) at www.mynmhc.org/Formulary.aspx for a complete listing of $0 copayment medications for NMHC members.

6. The Pediatric Vision benefit is underwritten and administered by VSP. Please refer to the VSP Pediatric Vision summary of benefits and the Plan’s Summary of Benefits for specific terms of coverage. 7. Only for individuals under the age of thirty (30) years, or a person age thirty (30) or older holding a Certificate of Exemption. All plans have an embedded deductible and out-of-pocket maximum. These plans do not include pediatric dental services as required under the federal Patient Protection and Affordable Care Act. This coverage is available in the insurance market and can be purchased as a stand-alone product. Please contact your insurance carrier, agent, or the New Mexico Health Insurance Exchange (www.nmhix.com) if you wish to purchase pediatric dental coverage or a stand-alone dental insurance product.

Prior Authorization List

ID0029-0318

Authorization is a request for services, a procedure, or an admission to a hospital or facility that must be obtained before any such service is given or within 24 hours after an emergency. A prior authorization is required for services, procedures, or admissions that require medical necessity review. Prior authorization is not a guarantee of payment. The following services require prior authorization by New Mexico Health Connections (NMHC). We also require notification for certain other services so that we may assist you and your patients with discharge planning, care coordination, and case management. All services must be medically necessary and appropriate and meet NMHC coverage criteria where applicable. Services rendered by non-contracted providers must receive prior authorization except those provided in an emergency department. Claims will be reviewed to determine member eligibility at the time of service, benefit availability, evidence of coverage provisions, and claims payment agreements. Benefits are determined by each Member’s plan. Failure to obtain necessary prior authorization or provide notification within the stipulated time frame will result in denial of the service and associated costs.

Prior Authorization Resources

Online Prior Authorization Reference Guide www.mynmhc.org/medical-management.aspx

Electronic Prior Authorization Submission www.mynmhc.org/prior-authorization-requests.aspx

Download NMHC Prior Authorization Form www.mynmhc.org/provider-resources.aspx

Fax NMHC Prior Authorization Form Fax: 1-866-446-3774

Telephone Contact for Prior Authorization 1-855-7MY-NMHC (1-855-769-6642)

Telephone Contact for Specialty Pharmacy 1-800-880-1188

Authorization Review Process NMHC seeks to make the Authorization Review process as efficient and easy to use as possible. To this end, NMHC recommends electronic submission of prior authorization requests for expediency. If the beneficiary requires specialty care within 5 business days, or for an urgent issue, the process may be expedited with any of the following:

Expedited/Urgent Prior Authorization Requests

Urgent Electronic Prior Authorization Request www.mynmhc.org

Download NMHC Prior Authorization Form www.mynmhc.org/provider-resources.aspx

Urgent Prior Authorization Requests by Phone 1-855-7MY-NMHC (1-855-769-6642)

Urgent Prior Authorization Request by Fax 1-866-446-3774

Telephone Contact for Specialty Pharmacy 1-800-880-1188

New Technology Newly published/assigned codes and new/emerging therapy services or technology not listed may require prior authorization to determine medical necessity. Check with us before providing these types of services. This list is updated bi-annually, but may change at any time. Please refer to the version currently in effect by visiting our website at www.mynmhc.org.

Notification (No Prior Authorization Requirement) The following services require notification within 24 hours of the service, procedure, or admission. Clarification of services that require prior authorization as opposed to notification is provided in the right column. If uncertainty exists regarding the need for prior authorization as opposed to notification, the provider must contact NMHC for clarification.

2

Services Requiring Notification* Service Request Is Notification Required?

Acute Hospital Admissions:

• Medical

• Surgical

Yes, within 24 hours of admission.

• Notify NMHC of emergent admissions within 24 hours or the next business day of inpatient admission.

• Routine vaginal or cesarean section deliveries do not require medical necessity review; however, both delivery types require notification.

• Complete and send newborn enrollment forms within 30 days of delivery.

Observation Status (24 hours or fewer): Yes, within 24 hours.

• Observation Status, regardless of duration, as an adjunct to surgical/radiology procedures or procedures performed in ambulatory surgical units, require prior authorization.

Hospice Services

Yes, within 24 hours of hospice enrollment.

Dialysis

Yes, within 24 hours of therapy.

*All out-of-network physicians and hospital and ancillary service requests require prior authorization.

Services Requiring Prior Authorization*

Service Request Is Prior Authorization (PA) Required for In-Network Providers?

Admissions:

• Elective Procedures/Surgery

• LTAC, Rehabilitation, SNF

• Observation Stays Extending Beyond 24 hours

• Radiology Procedures Requiring Inpatient or Observation

Yes.

• All elective admissions require PA.

• Admission to any long-term acute care, rehabilitation or skilled nursing facility, requires PA.

• Observation status, regardless of duration, as an adjunct to surgical/radiology procedures or procedures performed in ambulatory surgical units, require PA.

Advanced Imaging:

• CT/CTA

• MRI/MRA

• Cardiac Nuclear Medicine Studies

• PET/SPECT

Yes. Exclusions: Imaging rendered in the following settings DOES NOT require prior authorization:

• Emergency department

• Inpatient setting

• Observation unit

Transportation/Transfers

• Non-emergent Ground Medical Transport

• Air Medical Transport

Yes.

Behavioral Health

• Applied behavioral analysis therapy

• Electroconvulsive therapy (ECT)

• Partial Hospitalization

• Inpatient Admission

• Transcranial Magnetic Stimulation

Yes.

3



PT/OT/ST/Rehabilitative/Habilitative Yes.

• PA is required after first 10 visits per health plan year if rendered by a physical, occupational, or speech therapist.

• PA is required for the initial and all subsequent visits if rendered by a chiropractor or acupuncturist.

Pharmacy, Specialty

• Medications including but not limited to: Biologics, Genomic drugs, Monoclonal Antibody and TNF Inhibitors. See www.mynmhc.org for a comprehensive list of medications requiring prior authorization.

Yes.

Durable Medical Equipment (DME)/External Prosthetic Appliances (EPA) and Supplies

Yes.

• Any equipment >$1,000 per single item in addition to the following services: o All rental equipment o Customized orthotics, prosthetics, braces o Oral appliances o Bone-anchored hearing aids and cochlear implants o Oxygen and related equipment o Insulin pumps and supplies o CPAP/BiPAP and sleep study equipment o Sleep study if >1 per member per 12 months

o Ventilators and related equipment o Dialysis equipment o Defibrillators and related equipment o Chest wall oscillation air-pulse generator system

and related equipment o Bone stimulators o Functional neuromuscular stimulators and

transcutaneous sequential muscle stimulation o Functional electrical stimulation and

transcutaneous nerve and/or muscle stimulation o Vagal nerve stimulators/spinal stimulators o Insulin pumps and/or continuous glucose monitors o Custom made and specially sized wheelchairs and

related equipment o Power wheelchairs and related equipment o Power operated vehicles and related equipment o Electric, semi-electric, air fluidized, and advanced

technology beds and related equipment o Non-specific, miscellaneous, and unlisted DME,

orthotic and prosthetic codes

Specialty Diagnostics/Treatments/Supplies/ Miscellaneous

Yes.

• 3D imaging

• Intima media thickness Testing

• Virtual colonoscopy/capsule endoscopy

4



• Continuous EEG monitoring (elective admission)

• Pneumograms/apnea monitors

• Therapy (physical, speech, occupational) after 10 visits

• Home health services (skilled nursing, PT, OT, ST) Yes.

• Clinical trials

• Experimental/investigational procedures

• Wound therapy, wound vacuum device, hyperbaric therapy

• Genetic counseling and testing (amniocentesis/chorionic villous/AFP test excluded)

• Specialty laboratory testing (ex. Oncotype)

• Diapers, incontinence products, and gloves

• Enteral formulas and nutritional supplements

• Infertility services

• Injectables/infusions over $300 including allergy prep

• Non-specific, miscellaneous, and unlisted treatments and supplies

Dental Services Yes.

• Inpatient facility and anesthesia services require PA.

• Services for dental injury require PA.

• Non-specific, miscellaneous, and unlisted dental treatments and supplies require PA.

Surgery/Specialty Procedures

Yes.

• All outpatient hospital/ambulatory surgery center (ASC) procedures (see exclusions below)

• Office-based surgical procedures (see exclusions)

• Implanted Medical Devices

• Cosmetic/plastic/reconstructive (all settings)

• Orthognathic/oral/TMJ treatments

• Weight loss/bariatric surgeries

• Transplant, solid organ, stem cell, bone marrow (including evaluation and travel expenses)

• Spinal fusion and vertebroplasty

• X-STOP® Spacer for spinal stenosis

• Ventricular assist device (VAD)

• Lung volume reduction

• Transaortic or transapical valve insertion or replacement

• Pain management procedures, including but not limited to: Symphathectomies, neurotomies, radiofrequency ablation, injection/infusions, blocks, pumps, implants, minimally invasive lumbar decompression, acupuncture

• Non-specific, miscellaneous, and unlisted surgeries and procedures

5


Services NOT Requiring Prior Authorization* (not an all-inclusive list) Service Request

Is Prior Authorization (PA) Required for In-Network Providers?

Exclusions: Examples of OFFICE-BASED procedures that are EXCLUDED from Prior Authorization:

No. The following examples DO NOT require PA:

• Biopsy/excision of malignant lesion

• Casting/Splinting

• Circumcision <28 days of age

• Colposcopy

• Endometrial/endocervical sampling

• Acupuncture services (except when Rehabilitative/ Habilitative/PT services are provided)

• Chiropractic services (except when Rehabilitative/ Habilitative/PT services are provided)

• Incision and drainage of abscess/aspirations/suturing

• Intrauterine device insertion/replacement/ removal

• Outpatient behavioral health services including neuropsychology and psychological testing

• PICC line placement

• PORT-A-CATH®

• Toenail removal/neuroma injection

• Vasectomy, office based

• Wound care debridement

Exclusions: Examples of AMBULATORY SURGICAL CENTER procedures that are EXCLUDED from Prior Authorization:

No. The following examples DO NOT require PA:

• Biopsy/excision of malignant lesion

• Bladder tumor

• Bronchoscopy

• Cerclage during pregnancy

• Cystourethroscopy

• Colonoscopy (direct visualization)

• Orchiopexy

• Sterilization

• TURP


11/27/2018 ID Cards

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Customer Service: 1-855-7MY-NMHC (1-855-769-6642)

Sales: (505) 322-2360 Toll-Free: 1-855-808-3568 Sales Fax: 1-800-734-1596

Headquarters: (505) 633-8020 Fax: 1-866-231-1344

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Claims and Eligibility Quick Reference Guide for Providers

ID0030-0119

CLAIMS

Paper submission

Mail paper claims to: New Mexico Health Connections P.O. Box 211468 Eagan, MN 55121

• Filing deadline is 90 days from the date of service. • Professional services (CPT) must be submitted on a CMS-1500

claim form. • Inpatient services must be billed on a UB-04 claim form. • Do not submit handwritten forms. • Do not use labels, stickers, or stamps on the claim form. • Do not send duplicate copies of information.

Electronic submission

NMHC’s clearinghouse is Change Healthcare, formerly known as Emdeon.

• The NMHC Payer ID is 45129. • X12 837 format is accepted. • Version 5010 compliance is required.

Claims status

NMHC Customer Service: 1-855-7MY-NMHC (1-855-769-6642), M-F, 8 a.m.-5 p.m.

Calls are limited to five claims inquiries per call.

Appeals and grievances

Send appeals/ grievances and supporting documentation to: New Mexico Health Connections P.O. Box 36719 Albuquerque, NM 87176

Find claims appeals information in the NMHC Provider Handbook or by visiting the Provider Portal on our website, www.mynmhc.org.

MEMBER ELIGIBILITY, PRIOR AUTHORIZATION

Verify member eligibility

• Online: www.mynmhc.org • Eligibility Verification (IVR) Line: 1-855-7MY-NMHC (1-855-769-6642) • Customer Service: 1-855-7MY-NMHC (1-855-769-6642), Monday-Friday, 8 a.m.-5 p.m. • Paper identification forms • NMHC member ID card

Prior authorization

NMHC Medical Management Department Phone: 1-855-7MY-NMHC (1-855-769-6642) Fax: 1-866-446-3774

• While NMHC requires members to have in-network primary care providers (PCPs), referrals to in-network specialists do not require prior authorization.

• You can find the Prior Authorization Request Form and additional information in your Provider Handbook or on our website, www.mynmhc.org.

PHARMACY SERVICES Call OptumRx at 1-800-282-3232, or OptumRx Prior Authorization Assistance: 1-800-880-1188; fax 1-866-511-2202.

VISION CLAIMS Call VSP at 1-800-877-7195.

OTHER RESOURCES Provider Services Department

1-855-7MY-NMHC (1-855-769-6642)

We are available to assist you with your questions or concerns. Additional provider services, resources, and handouts are available at www.mynmhc.org.

NMHC Care Connect Line (nurse line)

1-844-308-2552

24 hours a day, 7 days a week, 365 days a year. Bilingual services available. Exclusively for NMHC members and their covered dependents. If the situation warrants, the nurse may arrange a telephonic consultation with an MDLIVE® doctor.

How to Find a Provider in the NMHC Provider Directory

ID0373-0717 Page 1 of 3

Note to our Native American members: IHS, 638, and other tribal health facilities will be included at in-network rates,

even if they are not listed as part of our network.

You may search by specialty, provider detail, or location.

First, select either the Provider or Facility button at the top left of the search screen. Provider Search Search by specialty

• Choose a provider type from the drop-down menu, such as Any Type, Alternative Medicine Provider, Behavioral Health Provider, Pediatric Specialist, Primary Care Provider (PCP), or Specialist.

• You may narrow your results further by selecting a specialty for your provider type from the Specialty drop-down menu.

• If you are looking for a provider affiliated with a particular hospital, select a hospital from the Hospital Affiliation drop-down menu.

• You may enter a name of a medical group in the Medical Group field. Leave this field blank to broaden your search results.

Search by provider detail

• You may use this option to search only for PCPs, providers of a particular gender, providers who are accepting new patients, providers who speak certain languages, or to search by a provider’s name.

Search by location

• You may search for a provider within 5- to 50-mile range; only inside a zip code, city, state, or county; or by zip code, city, state, and/or county.

• The results will provide you with a Google map to assist you in locating your provider. Hospital affiliation, medical group affiliation, and board certification Information such as a provider’s hospital affiliations, medical group affiliations, specialty, and board certification are listed on the search results page and the details page. You can reach the details page by selecting the provider’s name on the results page. Facility Search (see page 3 for a list of facility types) Search by location

• You may search for a facility within a 5- to 50-mile range; only inside a zip code, city, state, or county; or by zip code, city, state, and/or county.

Search by specialty

• You may search by type of facility or type of service.

• You also may enter the name of a facility in the Facility Name field. Leave this field blank to broaden your search results.

How We Update Our Directory and Validate Data NMHC updates its data within 30 calendar days of receiving new information from either source, and provides the source, frequency of validation, and limitations for each of the following:

These tips should help make your provider search easier. ▪ You don’t have to enter the provider’s full

name. You can enter part of the first or last name.

▪ Always enter a zip code and select a value from the “Within” drop-down menu.

▪ Be sure to select an option from the “Specialty” drop-down menu, even if you are looking for a PCP.

of 3

• Name/address/phone: Except where noted, all information about this provider’s name, gender, hospital affiliation, office location, languages, and acceptance of new patients is self-reported by the provider. NMHC updates this information only upon the provider’s request. NMHC validates the accuracy of this information at least annually.

• Specialty: Specialty is self-reported by the provider and verified during credentialing when he or she first joins the network. The doctor verifies his or her training in the specialty or his or her board certification status. NMHC validates the accuracy of this information at least annually and formally during the credentialing process every three years.

• Additional locations: If the provider has additional offices, the directory will list them. NMHC validates the accuracy of this information at least annually and formally during the credentialing process every three years.

• Board certification: Board certification is voluntary. A board-certified doctor, after completing residency training in his or her specialty, has passed an exam and has met all the requirements established by the board. The American Board of Medical Specialties or the American Osteopathic Association verifies this information when the doctor first joins the network and at least every three years thereafter. You can verify the doctor’s current board status by visiting www.abms.org. Members can check the most current board certification status of a provider by going to the ABMS, American Medical Association, or AQA websites. NMHC validates the accuracy of this information at least annually and formally during the credentialing process every three years.

• Hospital affiliation: Hospital affiliation displayed on this page doesn’t necessarily indicate that the hospital is in-network. Please conduct a hospital search to confirm the hospital is in-network for your benefit plan. NMHC validates the accuracy of this information at least annually and formally during the credentialing process every three years.

• Medical group affiliation (if applicable): NMHC validates the accuracy of this information at least annually and formally during the credentialing process every three years.

The following providers are included in our provider directory for all plans and metal levels: All of our health plans are designed based on specific criteria, as well as New Mexico state regulatory criteria that we apply to select participating primary care providers and providers across the following specialties. Additional specialists are included if they meet our credentialing requirements to ensure members have access within a reasonable distance to the number and types of providers needed. Specialists as noted within the grid include those that meet minimum standards for clinical quality measures.

MEDICAL/SURGICAL BEHAVIORAL HEALTH Physician Doctor of Osteopathy

Medical Doctor Doctor of Osteopathy Medical Doctor (Psychiatrists)

Allied Professional Acupuncturist Anesthesiology Assistant Audiologist Certified Diabetic Educator Certified Nurse Midwife Certified Nurse Practitioner Certified Physician Assistant Certified Registered Nurse Anesthetist Chiropractor Dentist Doctor of Naprapathy Doctor of Oriental Medicine Occupational Therapist Optometrist Oral Maxillofacial Surgeon Oral Surgeon Physical Therapist Podiatrist Registered Dietician Speech Therapist/Pathologist

Alcohol and Drug Abuse Counselor Certified Psych Nurse Specialist Clinical Psychologist Marriage Family Therapist Mental Health Counselor Professional Art Therapist Social Worker

http://www.abms.org/

http://www.ama-assn.org/

http://www.aqaalliance.org/

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Note: NMHC’s selection criteria for hospitals and our selection criteria for providers is the same for all plans, whether purchased on or off the exchange. The following facility and ancillary providers are included in our provider directory for all plans and metal levels:

ORGANIZATIONAL PROVIDER TYPES Air Ambulance Facilities Ambulatory Surgical Center (Freestanding) Behavioral Health: Ambulatory Center Behavioral Health: Hospital and Partial Hospitalization Program Behavioral Health: Substance Use Disorder Rehabilitation Facility Birthing Center Durable Medical Equipment Provider Free-Standing Radiology Centers: MRI, Mammography, CT, X-Ray, Ultrasound Home Health Agencies Hospice Provider Hospital: Acute Care, Rehabilitation, Long-Term Care, Children’s Infusion Center Laboratories: Pathology, Clinical, Genetic, Drug Testing, Draw Stations Prosthetics and Orthotics Skilled Nursing and Long-Term Care Facility Sleep Study Center Urgent Care Centers

How We Select Hospitals for Our Network All NMHC health plans and metal levels (e.g., Gold, Silver, Bronze) both on and off the Exchange provide members with access to hospitals that were selected based on specific criteria. First we look at the number of hospitals in the counties where our plan provides coverage to members. We make sure that members can access our hospitals within a reasonable distance and drive time. When choosing hospitals to include in all of our plans and metal levels, we also review the performance of hospitals using the following measures from nationally recognized sources such as The Joint Commission, CMS Medicare, and The Leapfrog Group. Note: NMHC’s selection criteria for hospitals and our selection criteria for providers is the same for all plans, whether purchased on or off the exchange.

http://www.qualitycheck.org/consumer/searchQCR.aspx

https://www.medicare.gov/hospitalcompare/search.html

http://www.leapfroggroup.org/cp

http://www.leapfroggroup.org/cp

NOTICE OF PRIVACY PRACTICES

ID0045-1016 Page 1 of 2

Privacy Commitment Thank you for giving New Mexico Health Connections (NMHC) the opportunity to serve you. In the normal course of doing business, NMHC creates records about you and the treatment and services you receive from medical providers. The information we collect is called Protected Health Information (PHI). NMHC is committed to maintaining and protecting your privacy. We are required by federal and state law to protect the privacy of your PHI and to provide you with this Notice about how we safeguard and use it. You may ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will promptly provide you with a paper copy.

When we use or disclose your PHI, we are bound by the terms of this Notice. This Notice applies to all oral, electronic, or paper records we create, obtain, and/or maintain that contain your PHI.

This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.

How We Protect Your Oral, Written, and Electronic Information We understand the importance of protecting your PHI. We restrict access to your PHI to authorized workforce members who need that information for your treatment, for payment purposes and/or for health care operations. We will not disclose your PHI without your authorization unless it is necessary to provide your health benefits, administer your benefit Plan, support Plan programs or services, or as required or permitted by law. If we need to disclose your PHI, we will follow the policies described in this Notice to protect your privacy.

NMHC protects your PHI by following processes and procedures for accessing, labeling, and storing confidential records. Access to our facilities is limited only to authorized personnel. Internal access to your PHI is restricted to Plan employees who need the information to conduct Plan business. We train our workforce members on policies and procedures designed to protect you and your privacy. Our Privacy Officer monitors the policies and procedures and ensures that they are being followed and arranges for new hire and annual training on this important topic.

Notice of Confidentiality of Domestic Abuse Information The Domestic Abuse Insurance Protection Act (DAIPA) is a state confidentiality law. It protects a member’s confidential information if he or she is or has been involved in domestic abuse. This act regulates insurers’ and insurance support organizations’ use of confidential abuse information.

In processing your application for insurance or a claim for insurance benefits, we may receive confidential domestic abuse information from sources other than you. If this happens, we are prohibited from using it or any other confidential abuse information, or your status as a victim of domestic abuse as a basis for:

Denying or refusing to insure, renewing or reissuing, canceling, or otherwise terminating (ending) your health care coverage.

Restricting or excluding coverage.

Charging a higher premium for health coverage.

You have the right to access and correct all confidential domestic abuse information we may have about you. You have the right to inform us of your wish to be designated as a protected person. As a protected person, confidential information, such as your address and phone number, will remain confidential. We will disclose and transfer it only in accordance with state and federal laws.

If you wish to be designated as a protected person, please contact NMHC at (505) 633-8020 or 1-855-7MY-NMHC (1-855-769-6642).

How We Use and Disclose Your Confidential Information We may disclose your PHI without your written authorization if necessary while providing your health benefits. We may disclose your PHI for the following purposes:

Treatment. We may disclose your PHI to your health care provider for plan coordination; to help obtain services and treatment you may need; or to coordinate your health care and related services.

Payment. We may use and disclose your PHI to make coverage determinations; to obtain payment of premiums for your coverage; and to determine and fulfill our responsibility to provide your benefits. However, we are prohibited from using or disclosing genetic information to make any coverage determinations, such as eligibility or rate setting. We may also disclose your PHI to another health plan or a health care provider for its payment activities.

Health Care Operations. We may use and disclose your PHI for our health care operations, such as providing customer service; to support and/or improve the programs or services we offer you; or to assist you in managing your health. We may also disclose your PHI to another health plan or a provider who has a relationship with you so that it can conduct quality assessment and improvement activities.

Appointment Reminders and Treatment Alternatives: We may use and disclose your PHI for appointment reminders or send you information about treatment alternatives or other health-related benefits and services. You will have an opportunity to opt out of future communications.

Disclosure to Plan Vendors and Accreditation Organizations. We may disclose your PHI to companies with whom we contract if they need the information to perform the services they provide to us. We may also disclose your PHI to accreditation organizations such as the National Committee for Quality Assurance (NCQA) when the NCQA auditors collect Health Employer Data and Information Set (HEDIS®) data for quality measurement purposes. When we enter into these types of arrangements, we obtain a written agreement to protect your PHI.

Public Health Activities. We may use and disclose your PHI for public health activities authorized by law, such as preventing or controlling disease, reporting child or adult abuse or neglect to government authorities, or to close friends or family members who are involved in or help pay for your care. We may also advise your family members or close friends about your condition or location (such as that you are in the hospital).

Health Oversight Activities. We may disclose your PHI to a government agency that is legally responsible for oversight of the health care system or for ensuring compliance with the rules of government benefit programs, such as Medicare or Medicaid, or other regulatory programs that need health information to determine compliance.

For Research. We may disclose your PHI for research purposes, subject to strict legal restrictions.

To Comply with the Law. We may use and disclose your PHI as required by law.

Judicial and Administrative Proceedings. We may disclose your PHI in response to a court or administrative order and, under certain circumstances, a subpoena, warrant, discovery request, or other lawful process.

Law Enforcement Officials. We may disclose your PHI to the police or other law enforcement officials, as required by law in compliance with a court order, warrant, or other process or request authorized by law to report a crime or as otherwise permitted by law.

Health or Safety. We may disclose your PHI to prevent or lessen a serious and imminent threat to your health or safety or the health and safety of the general public or other person.

Government Functions. Under certain circumstances, we may disclose your PHI to various departments of the government such as the U.S. military or the U.S. Department of State.

Workers’ Compensation. We may disclose your PHI when necessary to comply with Workers’ Compensation laws. State law may further limit the permissible ways we use or disclose your PHI. If an applicable state law imposes stricter restrictions, we will comply with that state law.

Uses and Disclosures with Your Written Authorization We will not use or disclose your PHI for any purpose other than the purposes described in this Notice without your written authorization. The written authorization to use or disclose health information shall remain valid, which in no event shall be for more than twenty-four (24) months. You can revoke the authorization at any time.

Your Individual Privacy Rights When it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities.

Right to Request Additional Restrictions. You may request restrictions on our use and disclosure of your PHI for the treatment, payment, and health care operations purposes explained in this Notice. This may be done by means of an oral, written, or electronic request from you. While we will consider all requests for restrictions carefully, we are not required to agree to a requested restriction. If we do agree to the restrictions, we will abide by them.

Right to Receive Confidential Communications. You may ask to receive communications of your PHI from us by alternative means of communication or at alternative locations, if you believe that communication through normal business practices could endanger you. While we will consider reasonable requests carefully, we are not required to agree to all requests. Your request must specify how or where you wish to be contacted.

Right to Inspect and Copy Your PHI. You may ask to inspect or to obtain a copy of your PHI that is included in certain records we maintain. Under limited circumstances, we may deny you access to a portion of your records. If you request copies, we may charge you copying and mailing costs consistent with applicable law. If your information is stored electronically and you request an electronic copy, we will provide it to you in a readable electronic form and format.

Right to Amend Your Records. You have the right to ask us to amend your PHI that is contained in our records. If we determine that the record is inaccurate, and the law permits us to amend it, we will correct it. If your doctor or another person created the information that you want to change, you should ask that person to amend the information.

Right to Receive an Accounting of Disclosures. Upon your oral, written, or electronic request, you may obtain an accounting of disclosures we have made of your PHI, except for disclosures made for treatment, payment, or health care operations; disclosures made earlier than six years before the date of your request; and certain other disclosures that are exempted by law. If you request an accounting more than once during any 12-month period, we may charge you a reasonable fee for each accounting statement after the first one.

Right to Receive a Paper Copy of this Notice. You may contact Customer Care at the number on your Plan ID card to obtain a paper copy of this Notice.

If you wish to make any of the requests listed above under “Your Individual Privacy Rights,” you must notify the Plan in writing.

For More Information or If You Have Complaints If you have any questions about your privacy rights, believe that NMHC has violated your privacy rights or disagree with a decision that we made about access to your PHI, or if you want more information about your privacy rights or do not understand your privacy rights, you may contact our Privacy Officer at the following address or telephone number. If we discover a breach involving your unsecured PHI, we will notify you of the breach by letter or other method permitted by law.

Privacy Officer You may contact our Privacy Officer at: New Mexico Health Connections P.O. Box 36719 Albuquerque, NM 87176 (505) 633-8020

If you believe NMHC may have violated your privacy rights, you may also file a written complaint with the Secretary of U.S. Department of Health and Human Services, (HHS). Your complaint can be sent by email, fax, or mail to the HHS’ Office for Civil Rights (OCR). You can file a written complaint to: U.S. Department of Health and Human Services Office of Civil Rights 200 Independence Avenue, S.W. Washington, D.C. 20201 or by calling 1-800-368-1019. For more information, go to the OCR website: www.hhs.gov/ocr/privacy/hipaa/complaints.

We will not take any action against you if you exercise your right to file a complaint with us or the Secretary.

We may change the terms of this Notice at any time, and we may, at our discretion, make the new terms effective for all of your PHI in our possession, including any PHI we created or received before we issued the new Notice. The new Notice will be available upon request, on our website, and we will mail a copy to you.

http://www.hhs.gov/ocr/privacy/hipaa/complaints

11/27/2018 Frequently Asked Questions

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Are you looking forhealth insurance?

SHOP & ENROLL

Transparency

In the News

Career Opportunities

Board Members

Senior LeadershipTeam

Media Kit

Frequently AskedQuestions

Healthcare Reform

2440 Louisiana Blvd. NE, Suite 601 Albuquerque, NM 87110

Customer Service: 1-855-7MY-NMHC (1-855-769-6642)

Sales: (505) 322-2360 Toll-Free: 1-855-808-3568 Sales Fax: 1-800-734-1596

Headquarters: (505) 633-8020 Fax: 1-866-231-1344

Contacts for Producers

Contact Us

About Us

Frequently Asked Questions

QuestionsWho and what is New Mexico Health Connections?What is a CO-OP and why is it good for New Mexico?How is New Mexico Health Connections Funded?What types of plans does New Mexico Health Connections o�er?Where can I purchase insurance from New Mexico Health Connections?Can brokers sell products on the New Mexico Health Insurance Exchange?Are brokers paid commissions?Are employers o�ering insurance coverage required to o�er coverage to dependents ofemployees?Helpful Links

AnswersWho and what is New Mexico Health Connections?

New Mexico Health Connections (NMHC) is a non-pro�t health plan for New Mexicansestablished by the A�ordable Care Act. NMHC is a CO-OP – a Consumer Oriented and Operated health plan.Our focus is on individuals, especially the uninsured. NMHC insurance is available for purchase both on and o� the New Mexico Health InsuranceExchange.

What is a CO-OP and why is it good for New Mexico?

Other approaches to health coverage have been tried over and over, with mixed results. CO-OPs have been successful and popular in other industries. We believe, along with manyothers across the country, that it is time to bring this model to the health insuranceindustry.This is a free market. If we can o�er a plan that is on par with or better than existing plans,with similar or better bene�ts, many New Mexicans will have an obvious reason for joiningour Consumer Oriented and Operated plan and experiencing the bene�ts of a consumer-friendly organization.

How is New Mexico Health Connections funded?

New Mexico Health Connections received federal loans from the Centers for Medicare &Medicaid Services (CMS) for start-up and solvency expenses.We are operating on the premiums of our members and are on track to completely repaythose loans on schedule.Our business model has been reviewed and approved by CMS and has been independentlyreviewed by the Milliman Actuarial Company.

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11/27/2018 Frequently Asked Questions

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What types of plans does New Mexico Health Connections o�er?

New Mexico Health Connections o�ers HMO health plan products for individuals andfamilies.

Where can I purchase insurance from New Mexico Health Connections?

Individuals can purchase our insurance both on the New Mexico Health Insurance Exchangeand privately o� the Exchange through an insurance broker. Working with an insurancebroker is optional; individuals may also purchase NMHC insurance directly from ourwebsite.

Can brokers sell products on the New Mexico Health Insurance Exchange?

Yes. Brokers can assist their clients in purchasing products on the New Mexico HealthInsurance Exchange as well as directly from NMHC.

Are brokers paid commissions?

Yes, brokers are paid commissions for products sold either on the New Mexico HealthInsurance Exchange or directly from NMHC.

Are employers o�ering health insurance coverage required to o�er coverage todependents of employees?

No, employers are not required to o�er coverage to dependents of their employeesbeginning in 2014. Dependents who are not o�ered coverage may be eligible for a premiumtax credit through coverage on the Exchange.

Links to helpful information on the ACA and small business:

IRS: www.irs.govKaiser subsidy calculator: http://healthreform.k�.org/subsidycalculator.aspxInfo on the ACA from Healthreform.gov:http://www.healthreform.gov/about/answers.html#smallbusinessesGlossary of key terms from HHS: http://www.healthcare.gov/glossary/De�nitions of health insurance terms from the Federal Government’s InterdepartmentalCommittee on Employment-based Health Insurance:http://www.bls.gov/ncs/ebs/sp/healthterms.pdf

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ID0028-1118

Prior Authorization (PA) Request Form Fax completed form to: 1-866-446-3774

Phone number: 1-855-7MY-NMHC (769-6642) * = Required Information

Requestor’s Contact Name: ___________________________________

Requestor’s Contact Number: ____________________________

PATIENT INFORMATION

*Name: __________________________________________ *Date of Birth: ________________________________ *Member ID Number: ______________________________ *Member Phone Number: ________________________ *Service Is: ☐ Elective/Routine ☐ Expedited/Urgent Note: Select Expedited/Urgent to prevent serious deterioration in health or ability to regain maximum function. (For a claim denial or prior authorization denial, please submit an appeal through Customer Service at 1-855-769-6642.)

*REFERRAL SERVICE TYPE REQUESTED Inpatient

☐ Surgical Procedure ☐ Elective Admission ☐ Elective Observation ☐ Skilled Nursing Facility ☐ Rehabilitation ☐ Long-Term Acute Care

Outpatient ☐ Surgical Procedure ☐ PT, OT, ST ☐ Imaging ☐ Chiropractic ☐ Acupuncture ☐ Infusion Therapy

Behavioral Health ☐ Inpatient ☐ Partial Hospitalization ☐ Intensive Outpatient ☐ Chemical Dependency ☐ Office Visits

Other ☐ Skilled Device (SN/PT/OT/SP) ☐ Durable Medical Equipment ☐ Dental ☐ Experimental/Investigational ☐ Transportation/Transfers ☐ ____________________

PROCEDURE INFORMATION

*ICD-10 Diagnosis: _______________________________

Diagnosis Description:

_______________________________________

*CPT/HCPCS Code and Description (Pricing is required for injections and durable medical equipment. Include unit of measure/frequency for supplies.): __________________________________________________________________________________________ _________________________________________________________________________________________________

* Date(s) of Service: __________________________ * Number of Visits: ____________________________________ PROVIDER INFORMATION

Ordering Provider: ☐ Primary Care Physician

*Name: ____________________________________ *NPI: ________________________ *TIN: ________________

*Fax: ______________________________________ *Phone: ______________________

*Address: _________________________________________________________________________________________ Servicing Provider: ☐ Same as Ordering

*Name: ____________________________________ *NPI: ________________________ *TIN: ________________

*Fax: ______________________________________ *Phone: ______________________

*Address: _________________________________________________________________________________________ Facility: ☐ N/A

*Name: ____________________________________ *NPI: ________________________ *TIN: ________________

*Fax: ______________________________________ *Phone: ______________________

*Address: _________________________________________________________________________________________

Request for extension to authorization: _________________________________________________________________

ATTACH CLINICAL NOTES/SUMMARY TO SUPPORT MEDICAL NECESSITY. INCOMPLETE INFORMATION MAY DELAY THE PROCESS. Disclaimer: An authorization is not a guarantee of payment. Member must be eligible at the time services are rendered. Services must be a covered Health Plan Benefit and medically necessary with prior authorization as per Plan policy and procedures.

Confidentiality: The information contained in the transmission is confidential and may be protected under the Health Insurance Portability and Accountability Act (HIPAA) of 1996. If you are not the intended recipient, any use, distribution, or copying is strictly prohibited. If you have received this facsimile in error, please notify us immediately and destroy this document.

Provider Claims Inquiry Form Please allow 4 weeks (electronic) and 6 weeks (paper) from submission date before inquiring on claim status.

Fax the completed form to 1-312-548-9943.

ID0059-0815

Date Requested: Contact Name:

Organization Name: TIN or NPI Number:

Business Phone Number: Fax Phone Number:

Member Name: Member ID Number:

Date of Birth: Date of Service: Billed Amount:

Servicing Provider: Status: (NMHC Use Only)

Completed By: _____________________________________________________ Date Faxed Back: _________________________

Claim Reassessment/Adjustment Request Form

ID0056-0319

Providers, facilities, and other ancillary care professionals should complete this form to request a claim reassessment. Do not use this form for formal appeals or grievances—please follow your standard appeals process and use the standard appeals and grievance form required.

Please mail this form and your corrected claims to: New Mexico Health Connections, P.O. Box 211468, Eagan, MN 55121, or fax it to 1-312-548-9943.

PROVIDER/GROUP/FACILITY INFORMATION Physician/Group/Facility Name:

Provider TIN/NPI Number:

Contact Name:

Phone Number: Fax Number:

Email Address:

Billing Address:

City: State: Zip Code:

MEMBER INFORMATION Member Last Name: First Name:

DOB: Member ID Number:

CLAIM INFORMATION ☐ Provider ☐ Facility ☐ Ancillary Health Care Professional (DME, Lab, etc.)

Claim Number: DOS:

Billed Amount: Paid Amount:

Reason: (Choose one of the adjustment request reasons from the drop-down menu below) Other- Please Enter Reason below

Reason:


CMS- 1500 Provider Definitions The following definitions apply to the provider terms used on the CMS-1500 paper claim form:

Referring Provider The referring provider is the individual who directed the patient for care to the provider that rendered the services being submitted on the claim form.

Examples include, but are not limited to the following:

• A primary care provider referring to a specialist • An orthodontist referring to an oral and maxillofacial surgeon • A physician referring to a physical therapist • A provider referring to a home health agency Ordering Provider The ordering provider is the individual who requested the services or items listed in Block D of the CMS-1500 paper claim form.

Examples include, but are not limited to, a provider ordering diagnostic tests, medical equipment, or supplies.

Rendering Provider The rendering provider is the individual who provided the care to the client. In the case where a substitute provider was used, that individual is considered the rendering provider.

An individual such as a lab technician or radiology technician who performs services in a support role is not considered a rendering provider.

Supervising Provider The supervising provider is the individual who provided oversight of the rendering provider and the services listed on the CMS-1500 paper claim form.

An example would be the supervision of a resident physician.

Purchased Service Provider A purchased service provider is an individual or entity that performs a service on a contractual or reassignment basis.

Examples of services include the following:

• Processing a laboratory specimen • Grinding eyeglass lenses to the specifications of the referring provider • Performing diagnostic testing services (excluding clinical laboratory testing) subject to Medicare’s antimarkup rule In the case where a substitute provider is used, that individual is not considered a purchased service provider

CMS-1500 Instruction Table The instructions describe what information must be entered in each of the block numbers of the CMS-1500 paper claim form. Block numbers not referenced in the table may be left blank. They are not required for claim processing.

Block No. Description Guidelines

1a Insured’s ID No. (for program checked above, include all letters)

Enter the client’s nine-digit patient number from the Medicaid identification form. For other property & casualty claims: Enter the Federal Tax ID or SSN of the insured person or entity.



2 Patient’s name Enter the client’s last name, first name, and middle initial as printed on the Medicaid identification form.

If the insured uses a last name suffix (e.g., Jr, Sr) enter it after the last name and before the first name.

3 Patient’s date of birth

Patient’s sex

Enter numerically the month, day, and year (MM/DD/YYYY) the client was born. Indicate the client’s gender by checking the appropriate box.

Only one box can be marked.

5 Patient’s address

Enter the client’s complete address as described (street, city, state, and ZIP code).

9 Other insured’s name

For special situations, use this space to provide additional information such as:

•

If the client is deceased, enter “DOD” in block 9 and the time of death in 9a if the services were rendered on the date of death. Enter the date of death in block 9b.

10a

10b

10c

Is patient’s condition related to:

a. Employment (current or previous)?

b. Auto accident?

c. Other accident?

Check the appropriate box. If other insurance is available, enter appropriate information in blocks 11, 11a, and 11b.

11

11a

11b

Other health insurance coverage

•

If another insurance resource has made payment or denied a claim, enter the name of the insurance company. The other insurance EOB or denial letter must be attached to the claim form.

• If the client is enrolled in Medicare attach a copy of the MRAN to the claim form.

•

For Workers Compensation and other property and casualty claims: (Required if known) Enter Workers’ Compensation or property and casualty claim number assigned by the payer.

11c Insurance plan or program name

Enter the benefit code, if applicable, for the billing or performing provider.

12 Patient’s or authorized person’s signature

Enter “Signature on File,” “SOF,” or legal signature. When legal signature is entered, enter the date signed in eight digit format (MMDDYYYY).

TMHP will process the claim without the signature of the patient.



14 Date of current Enter the first date (MM/DD/YYYY) of the present illness or injury. For pregnancy enter the date of the last menstrual period.

If the client has chronic renal disease, enter the date of onset of dialysis treatments.

Indicate the date of treatments for PT and OT.

17

17b

Name of referring physician or other source

Enter the complete name (block 17) and the NPI (block 17b) of the attending, referring, ordering, designated, or performing (freestanding ASCs only) provider.

Refer to specific sections for requirements.

in the following situations:

The attending physician for:

• Clinical pathology consultations to hospital inpatients or outpatients

• Services provided to a client in a nursing facility (skilled nursing facility [SNF], intermediate care facility [ICF], or extended care facility [ECF])

The referring physician for:

• Services provided to managed care clients (must be the client’s primary care provider).

Note:

If there is not a referral from the primary care provider, a prior authorization number (PAN) must be on the claim.

• Consultation services • CCP services • Radiology services. • Radiation therapy services.

The ordering physician for:

• Laboratory and radiology services • Speech-language therapy • Physical therapy • Occupational therapy • In-home TPN services

The designated provider for nonemergency services provided to limited clients on referral.

The performing provider (surgeon) for freestanding ASCs.

19 Reserved for local use

Transfers of multiple clients

If the claim is part of a multiple transfer, indicate the other client’s complete name and Medicaid number.

Ambulance Hospital-to-Hospital Transfers



Indicate the services required from the second facility and unavailable at the first facility.

20 Outside lab Check the appropriate box. The information may be requested for retrospective review.

If “yes,” enter the provider identifier of the facility that performed the service in block 32.

21 Diagnosis or nature of illness or injury

Enter up to four ICD-9-CM diagnosis codes to the highest level of specificity available.

23 Prior authorization number

Enter the PAN issued by TMHP.

For Workers Compensation and other property and casualty claims, this is required when prior authorization, referral, concurrent review, or voluntary certification was received.

24 (Various) General notes for blocks 24a through 24j:

• Unless otherwise specified, all required information should be entered in the unshaded portion.

•

If more than six line items are billed for the entire claim, a provider must attach additional claim forms with no more than 28-line items for the entire claim.

• For multi-page claim forms, indicate the page number of the attachment (for example, page 2 of 3) in the top right-hand corner of the claim form.

24a Date(s) of service

Enter the date of service for each procedure provided in a MM/DD/YYYY format. If more than one date of service is for a single procedure, each date must be given on a separate line.

NDC

In the shaded area, enter the NDC qualifier of N4 and the 11-digit NDC number (number on packaged or container from which the medication was administered).

Do not enter hyphens or spaces within this number.

Example: N400409231231

Refer to: Subsection 6.3.4, “National Drug Code (NDC)” in this section.

24b Place of service

Select the appropriate POS code for each service from the table under subsection 6.3.1.1, “* Place of Service (POS) Coding” in this section.

24c EMG (THSteps medical checkup

Enter the appropriate condition indicator for THSteps medical checkups.

Refer to:

Subsection 5.3.4, “THSteps Medical Checkups” in Children’s Services Handbook (Vol. 2, Provider Handbooks).


http://www.tmhp.com/HTMLmanuals/TMPPM/Current/Vol1_06_Claims_Filing.08.042.html#1760739


http://www.tmhp.com/HTMLmanuals/TMPPM/Current/Vol2_Children's_Services_Handbook.17.295.html#2221629


condition indicator)

24d Fully describe procedures, medical services, or supplies furnished for each date given

Enter the appropriate procedure codes and modifier for all services billed. If a procedure code is not available, enter a concise description.

NDC

Optional: In the shaded area, enter a 1- through 12-digit NDC quantity of unit.

A decimal point must be used for fractions of a unit.


24e Diagnosis pointer

Enter the line item reference (1, 2, 3, or 4) of each diagnosis code identified in block 21 for each procedure.

Indicate the primary diagnosis only. Do not enter more than one diagnosis code reference per procedure. This can result in denial of the service.

24f Charges Indicate the usual and customary charges for each service listed. Charges must not be higher than fees charged to private-pay clients.

24g Days or units If multiple services are performed on the same day, enter the number of services performed (such as the quantity billed).

Note: The maximum number of units per detail is 9,999.

NDC

Optional: In the shaded area, enter the NDC unit of measurement code.


24j Rendering provider ID # (performing)

Enter the provider identifier of the individual rendering services unless otherwise indicated in the provider specific section of this manual.

Enter the TPI in the shaded area of the field.

Entered the NPI in the unshaded area of the field.

26 Patient’s account number

Optional: Enter the client identification number if it is different than the subscriber/insured’s identification number.

Used by provider’s office to identify internal client account number.

27 Accept assignment

Required





All providers of Texas Medicaid must accept assignment to receive payment by checking Yes.

28 Total charge Enter the total charges.

For multi-page claims enter “continue” on initial and subsequent claim forms. Indicate the total of all charges on the last claim.

Note: Indicate the page number of the attachment (for example, page 2 of 3) in the top right-hand corner of the form.

29 Amount paid Enter any amount paid by an insurance company or other sources known at the time of submission of the claim. Identify the source of each payment and date in block 11. If the client makes a payment, the reason for the payment must be indicated in block 11.

30 Balance due If appropriate, subtract block 29 from block 28 and enter the balance.

31 Signature of physician or supplier

The physician, supplier, or an authorized representative must sign and date the claim.

Billing services may print “Signature on File” in place of the provider’s signature if the billing service obtains and retains on file a letter signed by the provider authorizing this practice.

Refer to: Subsection 6.4.2.1, “Provider Signature on Claims” in this section.

32 Service facility location information

If services were provided in a place other than the client’s home or the provider’s facility, enter name, address, and ZIP code of the facility where the service was provided.

32A NPI Enter the NPI of the service facility location.

33 Billing provider info & PH #

Enter the billing provider’s name, street, city, state, ZIP+4 code, and telephone number.

33A NPI Enter the NPI of the billing provider.

33B Other ID # Enter the TPI number of the billing provider.



CPT only copyright 2012 American Medical Association. All rights reserved.

UB-04 CMS-1450 Paper Claim Filing Instructions The following provider types may bill electronically or use the UB-04 CMS-1450 paper claim form when requesting payment:

Provider Types

ASCs (hospital-based)

Comprehensive outpatient rehabilitation facilities (CORFs) (CCP only)

FQHCs

Note: Must use CMS-1500 when billing THSteps.

Home health agencies

Hospitals

• Inpatient (acute care, rehabilitation, military, and psychiatric hospitals) • Outpatient

Renal dialysis center

RHCs (freestanding and hospital-based)

Note: Must use CMS-1500 when billing THSteps.

If a service is rendered in the facility setting but the facility’s medical record does not clearly support the information submitted on the facility claim, the facility may request additional information from the physician before submitting the claim to ensure the facility medical record supports the filed claim.

Note: In the case of an audit, facility providers will not be allowed to submit an addendum to the original medical records

for finalized claims.

CLEAN CLAIM SAMPLE AND INSTRUCTIONS


UB-04 CMS-1450 Instruction Table The instructions describe what information must be entered in each of the block numbers of the UB-04 CMS-1450 paper claim form. Block numbers not referenced in the table may be left blank. They are not required for claim processing by TMHP.

Block No. Description Guidelines

1 Unlabeled Enter the hospital name, street, city, state, ZIP+4 Code, and telephone number.

3a Patient control number

Optional: Any alphanumeric character (limit 16) entered in this block is referenced on the R&S Report.

3b Medical record number

Enter the patient’s medical record number (limited to ten digits) assigned by the hospital.

4 Type of bill (TOB) Enter a TOB code.

First Digit—Type of Facility:

1 Hospital 2 Skilled nursing 3 Home health agency 7 Clinic (rural health clinic [RHC], federally qualified health center [FQHC], and renal dialysis center [RDC]) 8 Special facility

Second Digit—Bill Classification (except clinics and special facilities):

1 Inpatient (including Medicare Part A) 2 Inpatient (Medicare Part B only) 3 Outpatient 4 Other (for hospital-referenced diagnostic services, for example, laboratories and X-rays) 7 Intermediate care

Second Digit—Bill Classification (clinics only):

1 Rural health 2 Hospital-based or independent renal dialysis center 3 Free standing 5 CORFs

Third Digit—Frequency:

0 Nonpayment/zero claim 1 Admit through discharge 2 Interim-first claim 3 Interim-continuing claim 4 Interim-last claim 5 Late charges-only claim



6 Adjustment of prior claim 7 Replacement of prior claim

6 Statement covers period

Enter the beginning and ending dates of service billed.

8a Patient identifier Optional: Enter the patient identification number if it is different than the subscriber/insured’s identification number.

Used by providers office to identify internal patient account number.

8b Patient name Enter the patient’s last name, first name, and middle initial as printed on the Medicaid identification form.

9a–9b Patient address Starting in 9a, enter the patient’s complete address as described (street, city, state, and ZIP+4 Code).

10 Birthdate Enter the patient’s date of birth (MM/DD/YYYY).

11 Sex Indicate the patient’s gender by entering an “M” or “F.”

12 Admission date Enter the numerical date (MM/DD/YYYY) of admission for inpatient claims; date of service (DOS) for outpatient claims; or start of care (SOC) for home health claims.

Providers that receive a transfer patient from another hospital must enter the actual dates the patient was admitted into each facility.

13 Admission hour Use military time (00 to 23) for the time of admission for inpatient claims or time of treatment for outpatient claims.

14 Type of admission Enter the appropriate type of admission code for inpatient claims:

1 Emergency 2 Urgent 3 Elective 4 Newborn (This code requires the use of special source of admission code in Block 15.) 5 Trauma center

15 Source of admission

Enter the appropriate source of admission code for inpatient claims.

For type of admission 1, 2, 3, or 5:

1 Physician referral 2 Clinic referral 3 Health maintenance organization (HMO) referral



4 Transfer from a hospital 5 Transfer from skilled nursing facility (SNF) 6 Transfer from another health-care facility 7 Emergency room 8 Court/law enforcement 9 Information not available

For type of admission 4 (newborn):

1 Normal delivery 2 Premature delivery 3 Sick baby 4 Extramural birth 5 Information not available

16 Discharge hour For inpatient claims, enter the hour of discharge or death. Use military time (00 to 23) to express the hour of discharge. If this is an interim bill (patient status of “30”), leave the block blank.

17 Patient Status For inpatient claims, enter the appropriate two-digit code to indicate the patient’s status as of the statement “through” date.

Refer to:

Subsection 6.6.6, “Patient Discharge Status Codes” in this section.

18–28 Condition codes Enter the two-digit condition code “05” to indicate that a legal claim was filed for recovery of funds potentially due to a patient.

29 ACDT state Optional: Accident state.

31-34 Occurrence codes and dates

Enter the appropriate occurrence code(s) and date(s). Blocks 54, 61, 62, and 80 must also be completed as required.

Refer to: Subsection 6.6.5, “Occurrence Codes” in this section.

35-36 Occurrence span codes and dates

For inpatient claims, enter code “71” if this hospital admission is a readmission within seven days of a previous stay. Enter the dates of the previous stay.

39-41 Value codes Accident hour–For inpatient claims, if the patient was admitted as the result of an accident, enter value code 45 with the time of the accident using military time (00 to 23). Use code 99 if the time is unknown.

For inpatient claims, enter value code 80 and the total days represented on this claim that are to be covered. Usually, this is the difference between the admission and discharge dates. In all circumstances, the number in this block is equal to the number of covered accommodation days listed in Block 46.





For inpatient claims, enter value code 81 and the total days represented on this claim that are not covered.

The sum of Blocks 39–41 must equal the total days billed as reflected in Block 6.

42-43 Revenue codes and description

For inpatient hospital services, enter the description and revenue code for the total charges and each accommodation and ancillary provided. List accommodations in the order of occurrence.

List ancillaries in ascending order. The space to the right of the

dotted line is used for the accommodation rate.

NDC

Enter N4 and the 11-digit NDC number (number on packaged or container from which the medication was administered).

Optional: The unit of measurement code and the unit quantity with a floating decimal for fractional units (limited to 3 digits) can also be submitted but they are not required.

Do not enter hyphens or spaces within this number.

Example: N400409231231GR0.025


44 HCPCS/rates Inpatient:

Enter the accommodation rate per day.

Match the appropriate diagnoses listed in Blocks 67A through 67Q corresponding to each procedure. If a procedure corresponds to more than one diagnosis, enter the primary diagnosis.

Each service and supply must be itemized on the claim form.

Home Health Services

Outpatient claims must have the appropriate revenue code and, if appropriate, the corresponding HCPCS code or narrative description.

Outpatient:

Outpatient claims must have the appropriate Healthcare Common Procedure Coding System (HCPCS) code.

Each service, except for medical/surgical and intravenous (IV) supplies and medication, must be itemized on the claim form or an attached statement.

Note:

The UB-04 CMS-1450 paper claim form is limited to 28 items per outpatient claim. This limitation includes surgical procedures from Blocks 74 and 74a-e.




If necessary, combine IV supplies and central supplies on the charge detail and consider them to be single items with the appropriate quantities and total charges by dates of service. Multiple dates of service may not be combined on outpatient claims.

45 Service date Enter the numerical date of service that corresponds to each procedure for outpatient claims. Multiple dates of service may not be combined on outpatient claims.

45 (line 23)

Creation date Enter the date the bill was submitted.

46 Serv. units Provide units of service, if applicable.

For inpatient services, enter the number of days for each accommodation listed. If applicable, enter the number of pints of blood.

When billing for observation room services, the units indicated in this block should always represent hours spent in observation.

47 Total charges Enter the total charges for each service provided.

47 (line 23)

Totals Enter the total charges for the entire claim.

Note:

For multi-page claims enter “continue” on initial and subsequent claim forms. Indicate the total of all charges on the last claim and the page number of the attachment (for example, page 2 of 3) in the top right-hand corner of the form.

48 Noncovered charges

If any of the total charges are noncovered, enter this amount.

50 Payer Name Enter the health plan name.

51 Health Plan ID Enter the health plan identification number.

54 Prior payments Enter amounts paid by any TPR, and complete Blocks 32, 61, 62, and 80 as required.

56 NPI Enter the NPI of the billing provider.

57 Other identification (ID) number

Enter the TPI number (non-NPI number) of the billing provider.



58 Insured’s name If other health insurance is involved, enter the insured’s name.

60 Medicaid identification number

Enter the patient’s nine-digit Medicaid identification number.

61 Insured group name

Enter the name and address of the other health insurance.

62 Insurance group number

Enter the policy number or group number of the other health insurance.

63 Treatment authorization code

Enter the prior authorization number if one was issued.

65 Employer name Enter the name of the patient’s employer if health care might be provided.

67 Principal diagnosis (DX) code and present on admission (POA) indicator

Enter the ICD-9-CM diagnosis code in the unshaded area for the principal diagnosis to the highest level of specificity available.

Required: POA Indicator—Enter the applicable POA indicator in the shaded area for inpatient claims.

Refer to:

Subsection 6.4.2.7.3, “Inpatient Hospital Claims” in this section for POA values.

67A-67Q

Secondary DX codes and POA indicator

Enter the ICD-9-CM diagnosis code in the unshaded area to the highest level of specificity available for each additional diagnosis. Enter one diagnosis per block, using Blocks A through J only.

A diagnosis is not required for clinical laboratory services provided to nonpatients (TOB “141”).

Exception:

A diagnosis is required when billing for estrogen receptor assays, plasmapheresis, and cancer antigen CA 125, immunofluorescent studies, surgical pathology, and alphafetoprotein.

Note: ICD-9-CM diagnosis codes entered in 67K–67Q are not required for systematic claims processing.

Required: POA indicator—Enter the applicable POA indicator in the shaded area for inpatient claims.

Refer to:


69 Admit DX code Enter the ICD-9-CM diagnosis code indicating the cause of admission or include a narrative

Note: The admitting diagnosis is only for inpatient claims.





70a-70c

Patient’s reason DX

Optional: New block indicating the patient’s reason for visit on unscheduled outpatient claims.

71 Prospective Payment System (PPS) code

Optional: The PPS code is assigned to the claim to identify the DRG based on the grouper software called for under contract with the primary payer.

72a-72c

External cause of injury (ECI) and POA indication

Optional: Enter the ICD-9-CM diagnosis code in the unshaded area to the highest level of specificity available for each additional diagnosis.

Required: POA indicator—Enter the applicable POA indicator in the shaded area for inpatient claims.

Refer to:


74 Principal procedure code and date

Enter the ICD-9-CM procedure code for each surgical procedure and the date (MM/DD/YYYY) each was performed.

74a-74e

Other procedure codes and dates

Enter the ICD-9-CM procedure code for each surgical procedure and the date (MM/DD/YYYY) each was performed.

76 Attending provider Enter the attending provider name and identifiers.

NPI number of the attending provider.

Services that required an attending provider are defined as those listed in the ICD-9-CM coding manual volume 3, which includes surgical, diagnostic, or medical procedures.

77 Operating Enter operating provider’s name (last name and first name) and NPI number of the operating provider.

78-79 Other Other provider’s name (last name and first name) and NPI.

Other operating physician—An individual performing a secondary surgical procedure or assisting the operating physician. Required when another operating physician is involved.

Rendering provider—The health-care professional who performed, delivered, or completed a particular medical service or nonsurgical procedure

Note: If the referring physician is a resident, Blocks 76 through 79 must identify the physician who is supervising the resident.

80 Remarks This block is used to explain special situations such as the

following:




•

The home health agency must document in writing the number of Medicare visits used in the nursing plan of care and also in this block.

• If a patient stays beyond dismissal time, indicate the medical reason if additional charge is made.

• If billing for a private room, the medical necessity must be indicated, signed, and dated by the physician.

•

If services are the result of an accident, the cause and location of the accident must be entered in this block. The time must be entered in Block 39.

•

If laboratory work is sent out, the name and address or the provider identifier of the facility where the work was forwarded must be entered in this block.

•

If the patient is deceased, enter the date of death and indicate “DOD”. If services were rendered on the date of death, enter the time of death.

• If the services resulted from a family planning provider’s referral, write “family planning referral.”

• If services were provided at another facility, indicate the name and address of the facility where the services were rendered.

• Request for 110-day rule for a third party insurance.

81A-81D

Code code (CC) Optional: Area to capture additional information necessary to adjudicate the claims. required when, in the judgment of the provider, the information is needed to substantiate the medical treatment and is not support elsewhere on the claim data set.


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